Baroness Cumberlege: rose to call attention to Her Majesty's Government's plans for the National Health Service; and to move for Papers.
	My Lords, I start by declaring an interest: I chair St George's, University of London; I am a senior associate of the King's Fund; and I have other connections with the National Health Service. For most of my life, the health service has been my life. I grew up in it and, like many people in this country and in your Lordships' House, I cherish it. I welcome this debate, and am pleased that, at this critical time, so many of your Lordships have chosen to take part. I am grateful to the Minister for being here today—I know it is at some personal cost. I particularly welcome back the right reverend Prelate the Bishop of Portsmouth and look forward to what he will tell us.
	The health service is an icon of Britishness, like wet summer holidays in Blackpool, garden vegetables and the man from the Pru. Yet Britain has moved on and the NHS has not. The delight of the NHS is that it was founded upon Christian Socialist ideals. It was a co-operative in the age when the co-op sent MPs to Parliament. Following in the steps of the mutual societies, it is a state mutual society—each according to their needs. The NHS arose out of two great wars, when the state ruled and we ate healthy food in rationed amounts. Times change, and in a consumerist society that ethic of mutuality no longer works. A cancer sufferer feels entitled to every chance of life that they can grab, regardless of cost. Others may lose out, but they must fight their own corner.
	That is a radical change; the foundations of the NHS are being eroded and we have to find a new ethic. The Labour Party has always considered that it has a head start with the NHS, because it perceived itself to be guardian of a socialist ethic. New Labour is not socialist and has no discernable ethic. The NHS needs one badly. This House is admirably suited to the job of replacing the philosophy of Beveridge with a new one, acceptable for today's society, and we should set about that task now. In the 1990s, we made a start in adapting the ethos of the NHS to reflect the change to a consumerist society, without losing its founding principles. In 1997, this change was swept away. Billions of wasted pounds and nine years later, the Government are trying to regain the position that they so carelessly threw away on arrival.
	I should like to explain. Up to two or three years ago I could, like any other working person, visit my GP at an evening or weekend surgery. That has gone. It went because of botched negotiations of the new GP contract. Now, in an extraordinary realisation of the obvious, the recent White Paper, Our Health, our care, our say, without a hint of humility, states:
	"we will introduce incentives . . . to offer opening times and convenient appointments which respond to the needs of patients".
	So the Government paid GPs to close down and now it pays them again to open up. That is not good management.
	I acknowledge that managing the NHS is not easy. There are, and always have been, two contrary forces pulling at the health service—local management and central control—but to veer from one to the other is simply crass.
	When the Government came to power, they inherited eight regional offices. Four years later, they were abolished in favour of four regional directorates. The directorates lasted just one year and were replaced by 28 strategic health authorities. The strategic health authorities now face the chop and are to be merged into about 10—almost the old regions back again. GP fundholding was scrapped and, nine years later, practice-based commissioning is to be put in its place. In 1997, the internal market had to go, to be replaced last year by payment by results. Here, policies could have been marginally adapted to achieve the same ends. Adaption is cheap but, of course, politically less heroic. This is about political egos versus good management.
	In 1998, 100 health authorities were abolished and primary care groups formed. They were swept away in favour of 303 primary care trusts. Established just three years ago, these trusts are now to be merged into about 130. Their staff are expected to implement the huge changes in the White Paper while they are worried stiff about their jobs, mortgages and schools for their children.
	In June, the PCTs were told to divest themselves of services such as district nursing, but in October the Secretary of State told them that that was not her plan. The Health Select Committee commented:
	"The Government's numerous announcements and subsequent retractions mean that it is still unclear what its policy is".
	The committee goes on to describe the Government's approach as "clumsy and cavalier", and states that PCT reform has,
	"produced a flawed and incoherent policy that is ill judged in the extreme".
	That is strong language for a Select Committee with a Labour chair and majority. The chairman of Basildon PCT told the committee:
	"some staff have had different employer names on their payslips five times in ten years".
	However, that is by no means all. Ministers have a penchant for agencies. Agencies are set up, as was the National Care Standards Agency, where all staff were recruited only for it to be abolished 14 days later in favour of another agency, the Commission for Social Care Inspection, which, in its turn, is to be amalgamated in 2008. We have seen the establishment of the NHS University and its demise. The Leadership Centre, the Modernisation Agency, the National Clinical Assessment Authority, the Commission for Health Inspection and the Commission for Patient and Public Involvement have all been here one minute and gone the next. The National Institute for Clinical Excellence, a great survivor, necessary and admirable, is supposedly independent but is now being undermined by a panicked Secretary of State who feels moved to start prescribing herself.
	Round and round we go, with managers and staff so dizzy that they fall off the carousel. Their falls cause injuries. They are not well looked after. The Christian Socialist ethic has been replaced by fear and recrimination. As the Select Committee said,
	"this approach to NHS staff has had a very damaging effect on staff morale".
	This is a nine-year chapter of bad management, which no commercial organisation could possibly survive. The Opposition have been patient. We have waited, and we have hoped that the extra money we welcomed will be well spent. Now we can no longer keep quiet. The top ministerial management is an embarrassment. It is hardly surprising that expenditure on the NHS has doubled in the face of all these changes and, according to the Office for National Statistics, there has been a less than 2 per cent increase in productivity. That is not bad; by any management criteria, it is a disgrace. It seems that just because the British public are compulsory subscribers, the Government have taken this as a writ to mismanage stupendously. Nicholas Timmins, the public policy editor of the Financial Times describes this expenditure bonanza as an opportunity squandered.
	Looking to the future, the Government have recently published a framework document for 2006–07 which bears little relationship to the White Paper. It tells us that 20 per cent of practices will be involved in practice-based commissioning by the end of this month. Really? They have hardly started. It also tells us that it will be 100 per cent within a year. I doubt it. With one or two exceptions, the Government have not managed to get clinical engagement. In lay language, the doctors do not want it. They are reluctant because they know the infrastructure is not there to support them. Computer systems are in their infancy and prone to break down. When I was a Minister, there were two consecutive years without a single case of home-grown measles. Not only have the Government been responsible for the debacle with the MMR vaccine, but the health of thousands of children is now being put at risk by significant failures in the new £6 billion NHS computer system. The system was imposed on primary care trusts and has destroyed 22 years of perfect record-keeping. As a community paediatrician told The Times:
	"The system is so bad, it's my opinion it will never work, but the department has spent so much, it's unwilling to go back and start again".
	When the internal market was scrapped in 1997, a gap was left in financial management. To fill this hole, payment by results—a tariff system for contracting services—was introduced. This is not small beer. By the end of this month, the total amount involved will be £9 billion, and in a year's time it will be £22 billion, or a third of the whole NHS budget. But one month before the start of the new financial year, the Department of Health finds that its figures are wrong. The tariff is withdrawn, and every finance director is left with months of worthless financial calculations, so no wonder there are expletives flying about.
	If management changes are irresponsible, managing the doctors of tomorrow is worse. Britain has a formidable reputation for medical training, not least because we have an enviable record in research and senior consultants with world reputations. It is good to see the Prime Minister, in his foreword to the White Paper, wanting,
	"change to be driven, not centrally, but . . . by the people who use services and by the professionals who provide them".
	Contrast this with the letter in last Saturday's Times from 86 of our most senior doctors, angry that they are not trusted even to select their junior medical staff. They write:
	"How is it conceivable that an untested computer programme should replace selection processes carefully developed by dedicated professionals over many years?".
	How many of us would choose a secretary by computer? We would want to meet the applicants and assess their strengths and weaknesses. The computer system is not management. It is number selection, fit only for the lottery and hurtful to consultants. If the Prime Minister wants the professionals to be in charge, this is hardly the way to trust them. If Ministers decide that computers should choose medical teams, Ministers must take the rap when things go wrong. Patient safety should override ministerial whim and, as chair of an outstanding medical school, I think that the future of young doctors should not be decided by a machine, particularly in a profession where human contact is so highly prized.
	The Royal College of Physicians has undertaken a review of professionalism—professionalism in 2006, not an archaic view. It has taken 15 months and I have had the privilege of chairing it. There was no froth, no spin and no crisis. It was a solid piece of work laying new foundations for the care of people's health, which is absolutely dependent on patients trusting their doctors. All the time that this review has been going on, the management of the NHS has been going on as well. The ministerial team has displayed all those qualities that a doctor should not show—vacillation, uncertainty, misdiagnosis and capricious changes in medication—which is impacting on doctors as they plod on trying to deliver a service through a hail of bullet points aimed at obscured targets.
	It is of huge concern that the management is now degenerating into a farce. Five years ago the chief executive of the NHS and the permanent secretary posts were amalgamated. Now they are to be split again, and I am very sad that Sir Nigel Crisp is the casualty of ministerial whim. He is a man of integrity and has given some stability in a department of ever changing ministerial teams. I am delighted that he is to come to this House and I am sure that he will be a contentious contributor.
	What we need now is a two-year moratorium on management change, a time for thought and reflection, intense debate, and a search for a world-beating team to restore the NHS to a world-beating service. I would ask that the first and instant result from this debate is the immediate cessation of the system of selecting junior doctors, for that is endangering lives, and that those 86 very senior and very sensible consultants who wrote to The Times should be shown respect. I beg to move for Papers.

The Lord Bishop of Portsmouth: My Lords, there is a saying that health is not valued until sickness comes, and that has certainly been my experience over the past six months, whether the word "health" means my own health or it means the health service. This debate is timely and I thank the noble Baroness for arranging it, and for her kind words, because if my calculations are correct, while the Minister was celebrating the anniversary of his arrival on this planet on 8 September last year, I was making preparations for my possible premature departure from it after being diagnosed with acute myeloid leukaemia. From that time until mid-January I spent about 11 and a half weeks in the tender and highly competent hands of the haematology unit of the Queen Alexandra hospital in Portsmouth. Perhaps I may place on the record not only my thanks to many noble Lords for their good wishes during my time away, but also my profound appreciation to Dr Mary Ganczakowski and her colleagues, to Kay Heron and Sue Thomas—who is no relation of the noble Baroness of that name—and their nurse colleagues. Without their professionalism, I would not be here to tell the tale. I can assure your Lordships that I am very much alive and kicking, and it must be the Viking genes in my bone marrow.
	I am aware that this is rightly a very technical debate. The fates have decreed that it comes when the National Health Service has entered the very forefront of public concern this week. As someone who could be described as a consumer rather than a professional, I want to confine my remarks to three areas: co-ordination, choice and stability. First, I turn to co-ordination. One of the issues arguably facing the NHS is continual reorganisation. Of course organisations sometimes need to be reorganised, but I have to say that the current plans to reorganise the PCTs—I live in the thick of one of those: Fareham, which has overspent considerably—could not be worse timed. I say that in the light of the recently announced plans to reorganise local government. Surely the cart is before the horse, or whatever image comes to mind.
	The balance is always between micro and macro management, but both are needed and it is a question of collective agreement and long-term policy about where each properly lies. The current plans have been severely criticised by the House of Commons Health Committee both because they come only three years after the previous reorganisation and because they are likely to set National Health Service organisations back by 18 months, with adverse effects on patient services. As a recently discharged patient, and I want to assure noble Lords that there are no special episcopal perks in the NHS aside from the odd joke, I want to be reassured that this will not be the case—and not just for acute treatment, but for other more day-to-day, non life-threatening programmes. I am concerned, for example, that drastically imposed economies on such apparently small, but for patients and their families highly significant issues as parking charges, do not get imposed. We were lucky in that respect.
	I do not want to labour the point unduly, but one of the most important keys to the well-being of a society is how it treats its most vulnerable people. Over the 10 years that I have been Bishop of Portsmouth, I have watched the Haslar hospital saga, and the growing consensus on the PFI at the Queen Alexandra hospital. While I have to say that the planned eventual closure of Haslar is not good news for Gosport—and I do try to keep the big picture in front of me—far too often one of the subtexts of the PFI plan seemed to paint a fanciful picture of a new building with plenty of land around and unlimited parking space, surrounded by a motorway ring road with easy access for all and sundry, including from the Isle of Wight, which is manifestly far from the case. Co-ordination means many things, from ensuring that patients do not suffer from casual or long-term economies to an adequate transport system—I am thinking of natal units as well as emergency cardiac treatment.
	Secondly, there is the issue of choice. I am afraid that the shibboleth about choice needs a bit of debunking. I am not against choice. I am glad that there was an array of newspapers in the service station on the M3 this morning. But when, after a gruelling weekend of three big services in unusually hot weather at the end of August last year, I realised that I needed to see my GP, I am glad that I was able to do so on that Monday morning and quickly. That is what people want. I would have gone in the evening if I had had to do so, but at least I got there.
	If I may speak for the church community with regard to consumerism, I was grateful to receive communion on Sunday mornings from whatever chaplain was available, regardless of denomination, and the form of service was not something about which I was prepared to grumble—especially during chemotherapy—or even write a letter to the local bishop, as that would be me. Moreover, I know that there are growing concerns among doctors, both general practitioners and those who work in hospitals, and among nurses, about the long-term effect of the rhetoric of choice on ordinary people's expectations. I am sure that this has played a part in the attacks on nurses that received national news coverage recently. Choice, whether we like it or not, is part of contemporary culture, and I echo the words of the noble Baroness. Perhaps the kind of reflective and more wisdom-based rather than technocratic changes that are needed should try to shift the language of public debate more in the direction of manageable, limited outcomes, in order to prevent an increasing outbreak of false expectations. Choice in healthcare may be relevant to some elective surgery, short-term treatments or diagnostic procedures, but it is far less appropriate for life-threatening or chronic conditions. When I was diagnosed, I did not want or need choice. What I needed and got was the security of immediate care, which in all its respects gave me the confidence to keep going, especially in those difficult early weeks.
	Thirdly, there is the issue of stability, by which I do not mean, "Stop the world, I want to get off," and nor do I mean no change—far from it. However, all organisations need a collective culture that builds up a sense of identity, with loyalty and allegiance as essential parts of its well-being. Charles Swinburne, the 19th century writer, may have been in one of his sharper moments when he wrote:
	"Body and spirit are twins; God only knows which is which".
	Part of any care organisation involves attending to both, however defined, religiously or not. There are inevitable positive spin-offs not only for the patient but for the whole ward.
	I do not envy a Labour Government having to face up to what is happening to one of their most precious jewels with which I grew up. There is a collective desire to get out of the mess. Briefly, I want to offer some advice from my work. If I want to set in motion a diocesan initiative, I know that I must convince a lay reader up the Meon valley, a church warden in inner urban Portsmouth and a country vicar in rural West Wight. I know that their first two questions to me will be: how does this initiative relate to the last one in addressing its weaknesses and building on its strengths; and how will it change things for the better on my patch?

Lord Harrison: I, too, thank the noble Baroness, Lady Cumberlege, for securing this debate and for encouraging those of us on this side of the House to return to our socialist roots. I believe that Nye Bevan would be turning in his grave with pleasure at the thought of the investment that has been put into the National Health Service by this enlightened Government over the past eight years. However, I want not simply to make a paean of praise, but to raise certain concerns. In doing so, I declare that I am president of the Parkinson's Disease Society in Chester, where we are very concerned, as are Parkinson's sufferers throughout the land, at the threat to PDS nurse specialists. They play a vital role in helping Parkinson's sufferers, and I hope and believe that the Minister will take that issue up.
	The Minister will also be aware of the importance of the medication regime. If it is disrupted for a Parkinson's sufferer, there is a problem controlling symptoms. I hope that he will lend his support to the Parkinson's Disease Society's "Get It On Time" campaign, which seeks to establish effective medicine-management systems, to ensure that Parkinson's patients get medication on time every time. I also alert him to my experience of dispensing pharmacies, which tell me that in certain areas they are having difficulties securing vital medicines from suppliers. In my area, Lantus insulin and metformin tablets, to help and treat people with diabetes types 1 and 2, are in short supply, with all the threats associated with that.
	It has been established that two out of five Parkinson's sufferers are unhappy with palliative care and believe that access to that care worsens as the disease advances. I hope too that the Minister will ensure that quality requirement No. 9 of the NSF for Long-term Conditions is applied rigorously. I share the concern of my noble friend Lady Pitkeathley about carers for Parkinson's. They play such a vital role in stabilising the lives of sufferers that I hope they are truly recognised by this Government, as I am sure they are. Finally on Parkinson's, I ask the Minister why free prescriptions are not accorded to Parkinson's sufferers, many of whom are below retirement age.
	I return to diabetes. I very much welcome the January 2006 White Paper, Our health, our care, our say. Proposals such as life checks, information prescriptions and personal care plans are good news for diabetics, who value the ability to manage their lives—and gain self-esteem thereby—as well as to be economically active. However, I ask my noble friend why there is a lack of clarification about the additional resources that must be attached to the very laudable plans enshrined in the White Paper. Does he recognise that changes in the NHS such as practice-based commissioning, payment by results and the shifting of care from hospitals to the community will have significant implications, and will he ensure that we do not have fragmentation of services?
	My final question on diabetes is a more general one of the money that has gone into the National Health Service, which is good and very welcome. However, the Government are setting a high priority on spending money wisely. I therefore ask the Minister to look at certain schemes—I gave him notice of one of them before the debate—in which I fear that money saved in the short term might be lost in the long term. The case to which I refer is that his department is commissioning research into commercial blood-sugar test equipment, and I hope that he is not guided simply by getting the cheapest price. The best equipment also has attached to it a good after-sales service, to make sure that it is tailor-made to patients. I give the example of two blind diabetics, for whom there was a capability of making a speaking monitor to give their blood-sugar results, thereby enabling them to remain at home and to lead active lives. They were therefore not always having to visit their GP or local hospital to make sure that their diabetes was properly under control.
	The second example is the laudable initiative by the Government to eliminate the number of missed appointments by patients at hospitals, which wastes money enormously. The Government have recognised the problem but I ask them please to ensure that those who might be struck off the list are properly advised and that that is not done without proper reference as to why they missed the appointments.
	Finally under this heading, it has been brought to my notice that money is sometimes wastefully expended. For instance, in the chiropody services, in the wake of the BSE outbreak, all equipment is being sterilised, regardless of whether procedures are invasive or not. Indeed, it has been computed in one PCT area that as much as £200,000 is spent on sterilisation of the appropriate equipment, but needlessly so. I hope that the Minister can turn his attention to that.
	My final remarks are about the European Union and the failure of how we deliver our health services and share best medical practice across the Union. I am fearful that we do not do enough of that and learn from the comparisons that we might make with fellow countries. I have in mind, for instance, France, where, yes, more money is spent on the health service as a proportion of GDP, but a good health service results. That means a healthy population and, therefore, an active economy. For instance, women are tested for breast cancer from 45 onwards, men for prostate cancer from 50 onwards and a general test is given to people from 46 onwards, thereby catching diseases early and enabling appropriate medication to be given. I believe that HMG is moving towards that, for instance with the proposals for life tests.
	One final point, which I am sure no one else will make in the House today, is that it would be encouraging if our medical professionals were given the proper language training within the European Union, so that they could converse and ensure the transaction of ideas. Ultimately, that would enable the benefit for all patients and practitioners to be spread more effectively throughout the United Kingdom and, indeed, the European Union.

Lord Fowler: My Lords, it is a pleasure to follow the noble Lord and particularly to congratulate my noble friend Lady Cumberlege on securing this debate, which could not have been better timed. I praise not just her speech, which was exceptional, but her dedicated interest in healthcare over the years.
	When I was Secretary of State for Health, my noble friend was one of my health authority chairmen, before she went on to higher and bigger things. That is rather different from the noble Lord, Lord Warner, who was previously a distinguished civil servant at the Department of Health. When I became Secretary of State and arrived at Elephant and Castle, he promptly handed in his cards and moved away. So there we are.
	I have three swift points to make. The first is to pinpoint a puzzle about the present-day health service. There is no doubt that the Government are spending more on the health service. I say that with a certain amount of envy, because I once did a waiting list initiative on £25 million. However, the real test is whether the extra resources are being used to best effect. If, for example, you spend a disproportionate amount on pay increases, the benefit to patient services is limited.
	What seems to be beyond doubt is that the public themselves do not always believe that the money is reaching the services. I saw a poll last week which asked whether people thought that the quality of the National Health Service had improved; 23 per cent said yes and 77 per cent said no. I recognise, as the noble Baroness, Lady Pitkeathley, pointed out, that when people are asked about their personal experience, those results are undoubtedly different, but that has always been the case—it was my defence when I was Secretary of State for Health.
	Add public concern to the big financial deficit and the resignation of Sir Nigel Crisp—to the discomfort of Ministers—and the press are writing not about success but about crisis in the health service. Perhaps the lesson here is that, whatever else, good management is of the essence in the health service. I remember that when I introduced general managers into the health service, it was fiercely opposed. My opponents said, "We do not want to see the health service run like Tesco". I am tempted to say, "If only", because the health service is like any other big organisation—it needs strong and skilled management locally and nationally.
	It always seemed to me, and seems to me particularly today, that at the centre one of the obstacles to good management—perhaps this lies behind the demise of Sir Nigel Crisp—is that there are far too many people intervening and double-guessing. Ministers, civil servants and politicians may sign up to the general proposition of moving resources north, but not if it affects their own area. I see also that the Prime Minister now has his own No. 10 health adviser. Why does the Prime Minister need his own health adviser? Surely his adviser is the health secretary. That was certainly my view when a similar proposition was put to me. If you go the other way, people do not know to whom they are answering. It blurs the lines of responsibility and is certainly not good management.
	As I went on in the health service, my view became that we would be better served if we could in some way separate policy development—properly the function of the Department of Health—from implementation and management of the service. My concept was for a health commission managing the service at arm's length from government, accountable to government but not run by it. I remember putting that to my noble friend Lady Thatcher. She thought for a little and then said, "No, they would say this was just a prelude to privatising it". There was no doubt that, at the time, that was exactly what would have been said, although I now note that the idea has the support of organisations such as the King's Fund.
	That brings me to my second point. No issue is more bedevilled by party politics than the health service. In my view nothing has done more harm over the years and stood more in the way of progress than that. I remember in 1983 publishing a circular entitled, Co-operation between the NHS and the private sector at district level—not exactly a threatening title. The idea was that, to reduce waiting lists, health service patients should have the opportunity of treatment in private hospitals, and health authorities should explore the potential of placing contracts with private nursing homes. That was described by Michael Foot as,
	"the most serious attack on the National Health Service since it was originally started".
	I am delighted that 20 years later it is now a mainstream policy of this Government. They rightly support co-operation between the private and voluntary sectors, because what matters is not what badge is being worn by the provider of healthcare but the quality and cost-effectiveness of that healthcare. Many people—some with vested interests—will snipe at that policy of co-operation, but I hope very much that the Government persist with it. In passing, I congratulate David Cameron on making it crystal clear that this party is not interested in introducing some new form of insurance system but is intent on developing the National Health Service. I hope therefore that there will be an end to all this nonsense about privatising the health service.
	My last point concerns an area where there is no doubt that the service has gone backwards—sexual health. We should remember that the sexual health clinics—the GUM clinics—pre-dated the National Health Service. They came out of a royal commission in the First World War and their purpose and achievement was to provide a free, anonymous walk-in service. Their justification was not just to help the individual, but to prevent the spread of disease. Today, 60 years after the inception of the National Health Service, we have delays before patients can be seen, and we have crowded waiting rooms and run-down premises.
	I am a trustee of the Terrence Higgins Trust, which, together with a number of other organisations, has just carried out a survey of provision, of which one section was devoted to the views of clinicians. I shall give one extract from it. The clinicians were asked:
	"Are HIV and sexual health sufficiently prioritised within your local health services?"
	Nineteen per cent said yes and 73 per cent said no. Yet we are in a position where sexually transmitted infections, including HIV, are the greatest infectious disease problem in the United Kingdom today: 1.5 million new episodes are seen in sexual disease clinics, over 60,000 people are living with HIV, and chlamydia is doing a great deal of damage, particularly to young women.
	Here you can correctly talk of crisis, for not only is our treatment falling short, but our prevention effort has been inadequate over the past 10 years. This is not a fashionable subject; politicians tend to be embarrassed by it or to avoid it. Something like HIV/AIDS does not come high up in the usual list of public concerns, yet it is a disease like other diseases, which is causing real damage to thousands of people. One test of the National Health Service is whether it deals with such challenges. I fear at present that this challenge has not been met. I urge the Government to put new energy and new purpose in bringing help here.

Baroness Murphy: My Lords, I add my thanks to the noble Baroness, Lady Cumberlege, for bringing forward the debate, not least because I agree with much of what she said. I also send a metaphorical hug across the Chamber to the noble Lord, Lord Fowler, for his words about the way that the NHS is now and should be perceived. I thank him very much, and much of what I say will echo his words.
	I have been in the health service now for 42 years. Now noble Lords are all looking at me wondering how old I am. I was an auxiliary nurse at Nottingham General Hospital before going to medical school. My first job was on John Player ward for respiratory diseases, where one of my jobs was to polish the brass ashtrays twice a week. So to anyone who thinks that the health service has not moved on—we have. I now have to visit several hospitals where I used to work as a houseman, notably Whipps Cross Hospital in east London. Anyone who thinks that the health service has not changed should come and see the difference. It has four times the amount of staff, and it has better qualified nurses and doctors than it ever had before. I had to work for a drunken consultant who was never there at night, struggling with an unqualified registrar to do surgical operations. That was in 1971. Frankly, the NHS has changed.
	Now I have moved on. I have been a clinical doctor and an academic for 25 years. I then became the chairman of a trust, the chairman of a health authority, and now I am in the stratosphere of the strategic health authorities. To me, that is a step too far for the next reorganisation. I have been through five of them; I am not going through another. The NHS cannot go on as it is. It has had a vast improvement in finances, which has been very welcome. In east London, we have had a 30 per cent uplift, which is the biggest uplift of any strategic health authority area. It was much needed in the areas that we serve, which have a diverse, impoverished population with very poor health records. There have been dramatic improvements in performance to targets; if you give us targets we will meet them. We always deliver the targets eventually. But patients are telling us that what they get from a rather mixed primary care service that is inadequate for the local population is not that much better. The patient experience has not improved enough in our poorest areas; there is still an attitude that people should be grateful for what they get.
	The noble Lord, Lord Fowler, referred—in other words—to the NHS as being a bit like a political football. But I remind your Lordships that, with a few hiccups, the broad thrust of the global forces of policy movement has been driven in the same direction. Conservative governments and now the Labour Government have moved quite a long way towards trying to separate out and introduce plurality of provision into hospitals, primary care and community services. To my mind that has been very much for the better. Self-governing trusts were the first thrust—they did not quite get there because we lost the bottle—and foundation trusts and foundation services introducing plurality of provision are the next, similar approach.
	Yet again, I am afraid, I see a lack of political bottle to see it through. You cannot introduce plurality of providers without recognising the need for a failure regime for those who cannot perform. We have some superb managers in the health service—I have worked in the independent sector and I know very well that we do not lack good and entrepreneurial managers—but in order to benefit from their talents we need to free them up, set them realistic goals and have sanctions for those who do not perform. We cannot have services carrying on, knowing that they will always be rescued.
	I am feeling pretty cross at the moment because of what has happened at my London strategic health authority. Your Lordships may all think from reading the papers that London is a basket case. Well, the North East London Strategic Health Authority will break even this year—and I am very pleased to say that—but what will happen to the money that it has not overspent? It will be loaned around to the other basket cases in London that have been overspending.
	The money that I was planning we should invest in the kinds of services referred to by the noble Lord, Lord Fowler—such as our desperately difficult and challenging sexual health services and the maternity services in east London, which are in dire straits—will be put on hold while we sort out the problems, again, in north-west London. Does that make good management? I suggest that it is not the managers that are at fault but the way in which they are supported within a national bureaucratic system.
	The NHS working like this is doomed to failure. There are no incentives to perform therefore it is not surprising that we have spent 50 per cent of the money on increasing salaries—some are worthwhile; others I have more doubts about—yet we have had almost no increase in productivity. Many services have improved, but nothing like as much as they should have done. Turnaround teams will come in and help failing hospitals but they will not be able to tackle the political issues involved in intervening to ensure that services which fail can be closed, taken over or removed. Monitor has raised this issue time and time again and I ask the Minister when we will have a failure regime.
	The second major problem is the weakness in commissioning and procuring services. We are now to have three layers. Primary care trusts have been largely a failure. We are going to reconfigure them to make them bigger, but will it make them better? I doubt it.
	I recently had a visit from representatives of the New York Public Health Department, which commissions services from the New York public hospitals. It is very striking that this is done by senior clinicians and senior nurses—people who have been in the services for years—negotiating with clinicians directly and shaping the future. In other words, they are negotiating like with like. What do we have? Junior managers commissioning services in primary care trusts. We have tried very hard in my patch to change that and to engage clinical leaders in all the services.
	But at the moment in Britain, clinical leadership of services is not what we expect. I was very proud to be one of the first clinical directors at Guy's after Sir Roy Griffiths's report in 1983. It seemed to me then that we were beginning to engage clinicians, but we have lost it again. Senior nurses and senior doctors began to run services and were proud of training to do it properly. We have lost that. Clinical leadership is absolutely crucial in running the health service right.
	My time is up so I will make my last point. Your Lordships would expect me, as a psychiatrist, to mention the mental health services. It was Enoch Powell who said that it is the acute, voracious hospitals which suck up the money in the health service. The new White Paper about hospital care is uncosted because the money will be sucked in, yet again, to the acute hospitals. The people who really suffer from this are those with profound, acute mental health problems. They could be treated and would be eminently able to lead fulfilling lives if we gave them the support they needed. We are failing, yet again, to recognise that that arm of the NHS requires more investment.

Lord Bilston: My Lords, I, too, thank the noble Baroness, Lady Cumberlege, for tabling the Motion today, which affords noble Lords—or myself at least—an excellent opportunity to place on record appreciation for the wonderful services provided in our National Health Service by those hundreds of thousands of dedicated professionals in every facet of healthcare throughout the UK. In every city and town in Britain, millions of patients each day are receiving health treatment, which is saving lives and healing bodies and minds, through modern methods of service delivery unequalled at any time during the history of the National Health Service. I contend that our Labour Government are truly fulfilling their commitment to the British people by modernising and energising the National Health Service and by making the vital investments to secure the major and minor improvements desired by everyone in our country.
	In the few minutes at my disposal I can give eminent testimony to this proposition by citing the tremendous improvements that have taken place in recent years in my home town of Wolverhampton. The Royal Hospital Trust in Wolverhampton has achieved considerable success in access to services since 1997. For the past year, the trust has ensured that no patient waits longer than 13 weeks for a first out-patient consultation; no patient waits longer than six months for a day case or in-patient treatment; patients requiring treatment for cataracts wait no longer than three months; and similarly for patients requiring interventional cardiology or cardiac surgery. Equally importantly, since October 2005, no patient has waited more than 26 weeks for a CT or MRI investigation, and the waiting time for endoscopy investigations and treatment is now six weeks. The trust complies with the maximum two-week wait—from GP to first out-patient appointment—and the 31-day diagnosis-to-treatment period. In addition, over 90 per cent of access targets for cancer are achieved for the 62-day urgent referral for treatment. These achievements have been hard won by consultants, doctors, nurses and auxiliary staff, to whom I pay tribute, along with our Labour Government, whose generous investment, including our overspend in Wolverhampton, has brought about these major improvements.
	This is by no means the end of the story. There is more good news. Thanks to the good judgment and foresight of my right honourable friend the former Secretary of State for Health, Alan Milburn, he approved the building of a 21st century state-of-the-art heart and lung centre during his period in office. It was one of the first developments of its type to be built in the UK, at an estimated cost of £57 million, and was built within budget and on programme. It was the biggest publicly funded scheme in the NHS at the time, funded wholly from the public purse. It is a magnificent facility, which has been serving the good folk of Wolverhampton, Dudley, Sandwell, Walsall, Worcester and south Staffordshire for the past two years, providing excellent treatment and care for a catchment area of more than a million people.
	I wish I had time to convey the many other additional and refurbished facilities implemented, such as the Deansley Centre for cancer services, which is also sub-regional and provides excellent cancer treatment and care; and the Benyon Centre, which operates a first-class children's service, and day case and in-patient facilities for gynaecology and endoscopy. In addition, since 2003, New Cross Hospital has had a new radiology department, offering a highly efficient and professional service, which removes from Wolverhampton patients the necessity of travelling to Birmingham or Stoke-on-Trent for diagnostic treatment. The primary care trust is also developing valuable community healthcare services, particularly in mental health, through the excellent leadership of Professor Jolley and his team.
	In conclusion, I say to the Minister: keep up the good work. I advise my right honourable friend the Prime Minister and my right honourable friend the Secretary of State for Health not to be overanxious about the additional expenditure. It is all beneficially contributing to rapidly improving patient care.

Baroness O'Cathain: My Lords, the National Health Service is just that: national. It is supported by us all, valued by us all and it is our responsibility to see that the service it delivers is the best possible for the nation—for all of us.
	Sadly, the current state of the NHS leads me to despair. This is not a political point; it is a statement of fact. The Government have poured money into the NHS, but with what result? There has been almost no increase in productivity, as the noble Baroness, Lady Murphy, so graphically described in a brilliant speech. There is, not to put too fine a point on it, chaos.
	The current situation, in so far as we can even begin to unravel what has gone so woefully wrong, has been addressed by the oldest and least respected management response to a problem: "throw more money at it". This is always a short-term response, but every investment should always be both forensically tested before undertaken and constantly monitored to make sure that the effects are as forecast. This has not happened, is not happening and, unless the most uncomfortable lessons of the current situation are learnt, we shall end up with an even greater mess than at present.
	In the 2004 spending review, the NHS is forecast to cost £76 billion in 2005–06. That, I repeat, is the spending review forecast, and takes no account of the deficits in the news this week. Those who say that even if the accumulated deficits amount to £l billion, or even £2 billion, this is not a gigantic problem as it amounts to only 0.12 per cent of GDP, should perhaps bear in mind that the reserve in the spending review amounts to £2.7 billion. Do the Government believe that no other department will overspend?
	Economists are frequently accused of manipulation of statistics, but there is no manipulation in my comments today—that I promise. The reality which the latest news of the deficits in the NHS brings into focus is that government expenditure is out of control. More than that, it is dangerously out of control. This affects the NHS in particular, but it also affects every other aspect of our economy.
	Government expenditure as a percentage of GDP has risen from 39 per cent in 1997–98 to a forecast of 41.9 per cent in this financial year—an increase in the proportion of the country's GDP of 7.4 per cent. The rise has been inexorable. If this rise had been matched by a corresponding increase in the efficiency and effectiveness of public services—particularly the NHS—there would be few who would criticise. However, this is patently not the case. The NHS is now in such a mess that every top brain that could be mustered should be mustered to try to help rescue it from a pathetic business situation where the staff are demoralised, the service is falling down in so many areas and, despite all the money thrown at it, deficits mount. Are Ministers listening to any of the messages being transmitted loud and clear from so many sections of the NHS?
	We have already heard, in brilliant speeches, that the NHS has been subjected to reorganisation after reorganisation. The wonderful doctors, nurses, and all other employees are confused. This is not an over-the-top comment. I have heard so much of it, and, knowing what trauma has been experienced in business by reorganisation after reorganisation, I can utterly appreciate the frustrations and insecurity that have arisen. A demoralised, frustrated and insecure workforce can never sustain top quality service over the long term, which is what matters to us all.
	Gaius Petronious, a Roman who had strong views, and has been proved right some 20 centuries later, famously vilified the concept of frequent reorganisation on the basis that it created an illusion of progress while producing chaos. My noble friend Lady Cumberledge gave us details of the merry-go-round of that process. When I was in business I had a quotation from Petronious on my desk, as did many of my colleagues in the companies in which I worked, and others. I recommend that Ministers—particularly those involved in the NHS—do likewise.
	A grim analysis, but the prognosis is even grimmer. The current situation cannot be allowed to continue. I do not want to criticise the Government, but I want to suggest that their lack of basic management experience and their gullible acceptance of the so-called solutions proposed by armies of consultancy experts must be addressed. There are many who can help, but they are not on the Government's radar screen. The genie has been let out of the bottle, and policies regarding the involvement of people willing to contribute their experience and expertise should be subject to much greater independent scrutiny.
	I was astonished to see proposals in the recent Natural Environment and Rural Communities Bill to the effect that non-executive directors appointed by government can have pensions. This would be totally out of order in the private sector. It is just another example of government throwing money at a problem, and this time turning a blind eye to the fact that the burden of public pensions commitment on every household in this country is £40,000, according to the news today.
	Please consult with people of proven international success in this country, even if they do not happen to be card-carrying members of the new Labour Party—this is another, less effective, way of endorsing what my noble friend Lord Fowler was saying. It is in everybody's interests that this problem should be addressed and solved. This is a matter of higher priority than anything else, other than the security of the state.
	Even before the news this week, I was shocked into the realisation that the situation of one significant sector of our population has deteriorated so much during the past few years. My shocked reaction was to the "Panorama" programme last Sunday evening on the long-term care of the elderly and infirm. I hope that the Minister saw the programme. If not, I suggest that he obtains a video recording and views it as soon as possible. The situation depicted in the programme was nothing short of scandalous. We are an ageing population, we are living longer and we can no longer rely on family to look after us at any age, even old age—or, indeed, middle age—due to the inexorable erosion by the Government of the importance of the family.
	During a 12-year period I had first-hand experience of the parlous state of those who try to exist while suffering from long term, hugely debilitating chronic illness. No one who has not gone through this has any conception of how devastating it can be. Our elderly and infirm are now on the scrap heap. There is no dignity and little compassion and there is intense worry about financing long-term care. Is that fair? Is that just? Is it what one of the leading countries in the world should be doing to those who have contributed all their lives to the state?
	I guess that it does not matter much to a Government who have so little respect or concern for the family. It does not matter that houses have to be sold and old people are left unable to pass on anything—other than debts for care—to their children and grandchildren. The NHS is there for them—but at what price? Free to all at point of need? Do not even bother to answer. I do not think so. Surely we must reassess where the NHS is going—and do it now. As the right reverend Prelate the Bishop of Portsmouth said, there is a collective desire to get out of this mess.

Baroness Masham of Ilton: My Lords, I thank the noble Baroness, Lady Cumberlege, for introducing the debate. I must declare an interest as I am a user of the National Health Service. I also have the privilege of being a member of many of the parliamentary health groups. Many of us from both Houses are kept up to date on health issues. Last night, I attended a dinner in another place. We were told how important it is to prevent deep vein thrombosis when patients go into hospital for operations. Each patient should have a risk assessment, and if they are at risk of blood clots and thrombosis they should be given blood thinners.
	Prevention is better than risking death, which can be prevented. More awareness of that matter should be made public and all doctors should know the risk. Far more people die of thrombosis in hospital than MRSA, but all those avoidable deaths should be prevented. I find many people using the National Health Service have problems of finding who provides what. I have come to the conclusion that it would be helpful to users of the National Health Service if there was an information hotline to the PCTs that could be of benefit to patients, carers and staff. The correct information is vital. It is not getting to the patients.
	The White Paper stresses health and social care working together in partnership. I have had experience of when that did not happen. We had to find which sling would be best for my husband, who for some time has had to use a hoist. The expert adviser on slings, who happened to be a health and safety officer from the hospital, advised that a sling made out of parachute silk, which could be sat on, would be the best. However, the occupational therapist from the social services who supplied the hoist would not agree to the parachute silk sling.
	I grew frustrated at such non-co-operation between two professionals, so I went to the firm that made the sling to buy one direct. That was not as simple as I thought it might be. It had to be sanctioned by one of the professionals. I had to chase the health sling expert all over the north of England on his mobile telephone as he worked part time as an adviser to several health establishments. Getting something as simple as a sling, which I was paying for, became a major frustration because I was convinced under our circumstances that that sling was the most suitable. I was not going to give up. Many people might have done, but in the end the sling arrived and it has been useful.
	In an ideal world of course people from the caring professions should work together in co-operation. However, it was evident from the "Panorama" programme on Sunday evening about nursing homes how difficult and expensive social care has become.
	I am president of the Spinal Injuries Association. We in the UK have been some of the leaders in spinal injury treatment. I hope that that will continue in the future of the NHS. It is absolutely proved that patients who have spinal cord injuries and go directly to spinal units, as long as their condition allows them to be moved, have fewer complications such as pressure sores, depression, and bowel and bladder complications than those kept in general hospitals. The Spinal Injuries Association fears that if PCTs run out of money patients may not be sent to spinal injury units. We would much prefer the money for that specialised treatment to be provided nationally.
	Last week I asked a bright young man, who was a tetraplegic and had been treated at Stoke Mandeville hospital, what he would suggest if he could have one improvement. Without hesitation, he said, "Better fresh cooked food". That would get patients better more quickly and would help to prevent pressure sores and be good for morale. Good food for better health should be a priority for such severely ill patients.
	I should like to bring to the Minister's notice the spinal unit at Oswestry. For those people who do not have suitable homes to go when they are ready for discharge, it has two halfway houses called Transhouse, one at Oswestry and one at Telford. They have all the facilities available for the patients to try out different equipment before the adaptations are carried out in their own homes. That avoids bed blocking and gives the patients time to get their houses sorted out. It would be of benefit if some other spinal units throughout the country had such facilities.
	There are so many demands on the NHS, but one section where improvements could be made seems to be for people who develop osteoporosis. Given that one in two women and one in five men over 50 will suffer a fracture, how do the Government justify the exclusion of osteoporosis from the quality and outcomes framework of the general medical services contract? What are the Government's plans to increase the early detection and treatment of individuals with osteoporosis, and will osteoporosis be included in the next review of the quality and outcomes framework?
	Further to the Government's announcement of additional funding over three years for DXA scanner machines, what measures are in place to ensure that the additional workforce and capacity are there in support? An estimated 3 million people in the UK suffer from osteoporosis. Every three minutes, someone in the UK has a fracture due to osteoporosis. Each year more there are more than 230,000 fractures in the UK. Osteoporosis costs the NHS and the Government more than £1.7 billion each year. The Government have a champion in the noble Baroness, Lady Royall. I hope that they will make use of her expertise as an adviser on the subject.
	I end by asking how the White Paper will be funded. Will the funding come from existing work streams in both health and social care or will there be any new money? How will the charging policies in social care be reconciled with healthcare where the premise is free at the point of need?

Lord Stone of Blackheath: My Lords, I must start by declaring an interest. I have chaired a health charity called DIPEx for three years, which provides patients with information to help them live with serious conditions and health issues. The NHS has embraced our work and has been a wonderful support. I will describe what DIPEx does more fully later. Health is not my field. My knowledge in this area comes from having been with Marks & Spencer for 34 years, when our involvement in the health and well-being of our staff was a core policy; and Tesco—mentioned earlier—learnt from us.
	Today I am going to talk about informing the patient. I learnt at M&S that when people have choices to make they want to know what other people did in similar situations. When people of any background are given time to talk about their illness, and are given help to understand their options by knowing what others did, their ability to cope is improved, their propensity to have better outcomes is enhanced, and it helps the well-being of their carers, friends and family.
	So on the basis of what I learnt at DIPEx and M&S, I want to congratulate the Minister and the NHS on their emphasis on providing patients with information, and to press upon the noble Lord the need for these services to include patient experiences. Secondly, I want to thank the department for the support it has already given to DIPEx and to remind the noble Lord that the young need special information and stories from their own generation. Finally, I suggest that the Government support a conference that will bring together all those who wish to help the NHS to get the right information to patients at the optimum time.
	Perhaps I may take a minute to quote from a book called Information Therapy written by Donald Kemper and Molly Mettler. They are developing, on a large scale, the concept of information prescription in North America. This quote from their book should give an idea of how it could apply to us here. As they come from Boise, Idaho, the original language is a bit American, so I have anglicised it a little for this quote. On the first page they say,
	"By offering every patient the right information 'prescription' as part of the process of care, the NHS can achieve measurable improvements in medical outcomes, patient safety, overall cost effectiveness of care and patient satisfaction".
	The White Paper, Our health, our care, our say: a new direction for community services, shows that the Government understand all this and are beginning to use the term "information prescription" and that they intend to develop a system of delivery in the UK by 2008.
	My first suggestion is that when developing information prescriptions for patients, of course people must have facts, and these facts must be properly researched. But people learn better from stories. So other patients' stories and experiences should also be available to patients and they must also be properly researched. If the Government were to include properly researched patients' stories in their information systems, this would be a powerful tool to help people make choices, give them support and help them manage their condition.
	Perhaps I may now explain what DIPEx already does in the UK. DIPEx is the patient information system that includes the real patient experiences. It is the patients' voice. We knew that newly diagnosed patients wanted to know what happened to other people in similar circumstances to their own: what choices did other patients make, and how did they feel now about the outcome of those crucial choices? This is exactly what DIPEx provides for them. It already has 33 separate sites: eight for cancers, four for the heart diseases and others for depression, epilepsy and rheumatoid arthritis. We are adding more every month.
	DIPEx has hundreds of voices of real patients talking about their real-life experiences and feelings. It is accessed heavily by patients and their friends. It is also used for training all levels of health professionals. It is unique in giving the real patients' perspectives from several angles. We ensure that with professional researchers, based mainly at Oxford University, covering patients' stories that include the good choices and experiences people had, the difficult periods and dilemmas for patients and their families, and, in some cases, the bad times and wrong paths people felt they had taken.
	We are really grateful for the Government's help and support since our inception, and for their encouragement recently to develop a new service YouthHealthTalk.org, which covers teenage cancer, sexual health for young people, acne, asthma, diabetes and the like. The department is supporting the launch of this young people's website on 22nd of this month, where Philip Pullman, the award-winning author, will be talking about the power of storytelling and Jon Snow, our founding patron, will explain how this new project will develop its own style for youth. So my second request is, of course, that the Government look favourably on the further funding needs of DIPEx and YouthHealthTalk.org.
	My final point could easily be made in the next debate on the value of the voluntary sector: that we are envied abroad. Wherever we talk of DIPEx with people concerned with patient information, be it in Europe, Australia, America or Russia, they say they have nothing as comprehensive as the voices we have collected at DIPEx. Our work is voluntarily organised by the trustees of our charity, and the stories are given voluntarily by good people who are ill and who know that they are helping others by telling us their stories.
	People around the world are so interested in what we are doing here that they want to include DIPEx-type interviews in their own patient information services. So my final suggestion is that the Government lend support to a conference that is to be arranged here in London later in the year, where those leading the developments in patient information will consider the concept of information prescriptions, discuss the importance of including properly researched patient experiences in all systems and what needs to be done to adapt the new information structures we are building here to get the right information to the right patient who needs it in the right dose. I hope that the Minister might agree to speak at such a conference.

Lord Forsyth of Drumlean: My Lords, it is a pleasure to follow the noble Lord. What he said about patient information is very important. I know that everyone in the House will be delighted that the right reverend Prelate the Bishop of Portsmouth, who is no longer in his place, is back and restored to good health. He said that he could not see why people would want choice if they had a very acute condition. If I had a very acute condition, I would want to know where was the best place to go, and I would want to be able to make that choice. Information on that is clearly very important.
	I thank and congratulate my noble friend Lady Cumberlege not only on securing the debate but also on a devastating speech. Anyone listening to that speech must be asking themselves: why did Sir Nigel Crisp resign? Surely, it should have been the Secretary of State for Health. It is a damning indictment of the incompetence which has been shown by the Government. The fact that a senior civil servant has had to fall on his sword adds insult to injury. I am perhaps less charitable than my noble friend. I have to ask: what must it be like around the breakfast table in those households where the breadwinners are facing compulsory redundancy in the health service because of the financial mismanagement of this Government? They look at their newspapers—they are worried about their jobs—and what do they see? They see that the man who is apparently to blame is to be given a pension which most people could only dream of and a place in this House. What has happened to the concept of ministerial accountability? I suppose that the noble Lord, Lord Warner, will have some accountability when the newly ennobled Lord Crisp sits on these Benches and is able to ask him the questions, instead of providing the answers for the flip-flop policy which we have seen over a number of years. How can we expect people to have any confidence in our system if they see levels of incompetence on this scale and no one carrying the can for them?
	I was not impressed by the Secretary of State's response to this crisis, which was to go out the next day and make an announcement for a new £1 billion PFI project, for which people have been waiting years. Does she think that we are stupid; that we cannot see that this is just a piece of spin to try and draw attention away from the real crisis which is enveloping the health service?
	I give the Government credit. They have been as good as their word in increasing spending. NHS spending has been growing at 6.5 per cent in real terms. Public spending has grown in the biggest ever single leap; by 5 per cent of GDP. So the Government have certainly spent the money, but the money does not seem to be having much of an impact on the NHS where every year since 1997 productivity has fallen
	I very much enjoyed the speech of the noble Baroness, Lady Murphy, who asked a key question. Why should efficient health authorities in London find their plans damaged because they have to bail out other people? The Secretary of State should see to it that those who have been doing a good job should not be penalised. The King's Fund has estimated that 73 per cent of the new money going into the health service simply disappears like water in the desert soil. Of course, some of it is being spent on pay rises. I am second to no one in my respect and enthusiasm for the people who work in the health service, but they deserve better leadership than this.
	If we have this scale of crisis now, with spending running at 6.5 per cent in real terms, what will happen in 2008, when the Chancellor projects the increase in total public expenditure coming down to 1.8 per cent? I am pleased to say that I have the answer. It is in the form of a quote from the previous Secretary of State, Mr John Reid, who told the Health Service Journal,
	"after 2008 there'll be less demand on the primary and secondary sectors, but more importantly we will have got rid of the 1.25 million people who were on waiting lists. That should ease the challenge after 2008".
	Does he seriously believe that? If he does, he should not be anywhere near any government department or running anything. Anybody who has looked at the challenges facing the health service can see that fundamental reform is required.
	I shall give one example. I used to be in charge of the health service in Scotland. I spent £4.4 billion in my last year in office. Today, the expenditure in Scotland is more than £9 billion. In 1997, my in-patient waiting time was 34 days. I acknowledge that that was far too long; we paid a political price for it. The Minister shrugs his shoulders. Today, the waiting time has gone up to 44 days. Out-patient waiting times then were 16 days less than they are today. The number of people waiting for six months has more than trebled. Spectacular spending has produced longer waiting times and waiting lists. Only today, we discover that a bit of a mistake, an error of judgment, was made on the consultant contract in Scotland. As with the Scottish Parliament, big numbers are always involved. The error amounts to £273 million of unanticipated expenditure.
	This Government have tested to destruction the proposition that extra expenditure will result automatically in improved public services. So what is the remedy? The remedy lies in getting Whitehall out of interfering in the day-to-day activities of hospitals and GPs. It lies in breaking the state monopoly of the provision of patient services. I have a marvellous quotation which summarises what needs to be done. It states:
	"We must develop an acceptance of more market-oriented incentives with a modern, reinvigorated ethos of public service. We should be more radical about the role of the state as regulator rather than provider, opening up healthcare for example to a mixed economy under the NHS umbrella, and adopting radical approaches to self-health. We should also stimulate new entrants to the schools market, and be willing to experiment with new forms of co-payment in the public sector".
	More competition; ending the monopoly; bringing in charging: who said it? Was it David Cameron? No, it was Tony Blair, three years ago as Prime Minister. When will this Government put their rhetoric into practice? If they are prepared to do so, they will find common ground with people on these Benches and even some on the Liberal Democrat Benches. The truth is that they have been telling the people what they want to hear for far too long and the victims have been the sick and those in need of patient care, who are now suffering, along with the taxpayers, who are faced with liabilities and bills which are simply unsustainable.
	So let us look for a radical reform of the NHS. Let us acknowledge that this model has failed, in the way that the old nationalised industries failed. They failed because they did not have to please their customers; they failed, as the noble Baroness, Lady Murphy, pointed out, because they knew the taxpayer would always bail them out in the end; and they failed, most importantly of all, because they were constantly being interfered with by people who had political objectives and who were sitting in Whitehall, far too removed from the front line.
	I again congratulate my noble friend on the timing of this debate. Let us hope that the Government will learn from this lesson. Too many people have suffered. The Government set out—with the best intentions, I accept—on a policy which has produced a disastrous outcome.

Baroness Emerton: My Lords, I, too, thank the noble Baroness, Lady Cumberlege, for raising this debate and congratulate her on her excellent speech. In the short time available, I shall link a statement made yesterday on Radio Four's Today by the Secretary of State, the right honourable Patricia Hewitt, where she referred to the need to balance financial accounting with the delivery of high-quality patient care, and paragraph 1.47 in the Government's White Paper which states:
	"We need strategies for work force development that support radical shifts in service delivery and equip staff with the skills and confidence to deliver excellent services often in new settings. Staff will increasingly need to bridge hospital and community settings in their work".
	There is no doubt that much is to be done to redress the financial overspend, but there is a need also to redress the balance between emphasis on financial management and targets and patient care. The workforce will be required to meet this balance. The goals of the National Health Service remain unchanged; that is, the delivery of care to all at the point of need free of charge. The proposals for expansion of foundation hospitals and the proposals in the White Paper present many exciting challenges for new models of care, both in hospitals and the community. Certainly, these call for intensive workforce development to ensure that the highest quality of patient care is delivered.
	I was struck to hear a director of nursing and deputy chief executive of a foundation trust conclude his presentation last week on managing MRSA in his hospitals by saying that trying to engage board members' interest in anything to do with patient care was one of his most difficult tasks, because most of the members of the board were business people whose focus was on finance. He said that it was difficult to engage them in patient-care issues. Perhaps if patients were referred to as "customers", this might have more meaning to the members of that board. This point was again emphasised only two days ago by a group of 16 matrons and senior ward sisters who are on a clinical leadership course in a foundation trust in the Midlands and who came for a discussion with me in this House.
	Nursing has been my professional life—I have to confess, for a longer time than the noble Baroness, Lady Murphy, having gone through seven reorganisations. I am delighted that the Burdett Trust for Nursing has launched a Leadership and the Business of Caring project. It has commissioned the Office for Public Management to carry out a study to form the basis for the development of executive nurses and the boards of which they are members. Performance management of patient care is as important as financial management if we agree that patients—or "customers"—are the business of the NHS. While all members of the healthcare team play an important role in the care pathways, the nurse is the member of the team who provides 24-hour care and plays an important advocacy role to patients and relatives.
	Much progress has been made in healthcare delivery, in prevention, diagnostics, treatments, rehabilitation and long-term care in a fast-changing society, all of which is well informed. However, the media periodically expose some aspects of care that are far from acceptable; for example, in nutrition, personal hygiene, or cross-infection. These basic issues will remain important to the patient. Will the Minister give consideration to ensuring that a nominated person is given the responsibility, with authority for performance management of clinical care, to reflect care from the point of care delivery—that is; the bedside, health centre or clinic—through the organisation to the board? I am sure that the Minister will not be surprised if I suggest that this role might best be filled by the executive nurse on the board, who would not only fulfil the role of clinical performance manager, but also be the guardian of patient care, restoring care and compassion in whatever setting of healthcare delivery.
	As well as being a nurse, I declare being a volunteer for more than 59 years. I am pleased that the White Paper acknowledges the part that the voluntary sector plays in the provision of health and social care. I am chairman of the National Association of Hospital and Community Friends—soon to become known as Attend. We, in partnership with NAVSM, represent 100,000 volunteers over 1,000 sites, and in 2005 contributed over 1 million hours' service, while friends groups contributed £45 million to support services in health and social care.
	However, while the White Paper refers to barriers needing to be lowered—I will be speaking on that in today's debate—the Minister should take account of the current concerns over the late allocation of Section 64 and the OFV grants that are having a detrimental affect on patient care. Volunteers play an important part in supporting health and social care, and I trust that the Government will assist in promoting partnerships, as set out in the 2004 policy, "Compact".

Baroness Greengross: My Lords, I agree completely, but this inequality is also embedded in the health service through socio-economic status, which I shall come to, which affects our health and our life expectancy to an absolutely unacceptable extent. If we do not tackle this inequality in access to healthcare, the difference in life expectancy in the population is more than five years. This is not about differences in the tendency to become ill; it is about differences in socio-economic status. Professor Sir Michael Marmot and others working with him at UCL have demonstrated that very clearly.
	We must take a holistic approach that involves a national debate about how we are to distribute the treatments that people expect and deserve. I very much welcome the work already being done to bring together different aspects of care, such as health and social care, because people who have either acute illnesses or long-term illnesses do not fit into one silo. So far, because we have different methods of funding, we expect people to fit into those different silos, and it just does not work. It creates perpetual disputes. Cancer, for example, can involve treatment that does not apply if you suffer from Alzheimer's disease, when the care that you need comes under social care. Such differentiation is no longer acceptable.
	The noble Baroness, Lady O'Cathain, quite rightly pointed to the huge problem of long-term care, which we must do something about. One of the problems with long-term care and the way in which we allocate resources is that many people still need residential and nursing-home care and will go on needing it. There is a huge problem with care staff not being available or qualified to provide that sort of care, which is not in fact funded by the health service but by social care. These need to be brought together. This is the Cinderella part of the service. These people need to be educated and trained to professional standards. We welcome those rigorous standards, but increased costs are making nursing homes and residential care homes go broke and simply close down while the need for that sort of care is increasing. So there is a crisis in funding and retaining care staff and long-term care homes. I am privileged to be associated with organisations, which are mostly voluntary but include academic bodies, that are looking into how that training and professionalism of care staff might be improved. That is part of the holistic approach that we need to take.
	We must consider the huge mental health problems across Europe—about 80 million people will need mental health treatment at some point in a year. That is another huge priority which we need to take into account if we are to consider the long-term future of the NHS and make it work.

Lord Selsdon: My Lords, one of the great advantages of being elected to this House by your peers is that you have the privilege of learning from professionals from time to time without being subject to elective surgery. I speak today as a total amateur in this subject. I admit that I have absolutely no idea how most parts of my body work, and I find that I have many common allies in the United Kingdom, but once you move into the international realm, the knowledge of what your body does, what biliary cirrhosis is or what each component ingredient mixes with, even with the knowledge of food, is important.
	I was reminded of this when I saw a surgeon the other day and asked for advice. I said, "But surely surgeons are the most important people in hospitals. They are the dictators, the demigods, the gods". He said, "Yes, but we suffer from OCD"—I think he said obsessive compulsory disorder or something. I found that I knew nothing about all the acronyms and other abbreviations that are passed around by professionals. In many countries, the word "amateur" is a compliment. It means someone who knows and loves his subject. I have suddenly found that I am compulsorily interested in health but, for reasons different from those of all your Lordships, I see it as a really great opportunity.
	I express particular thanks to my noble friend, who secured this debate, for adding so much through our colleagues today to my own personal knowledge. I appreciate it. I declare an interest in that my first involvement in the subject came when, by some accident or other, I was appointed to the board of the oldest health company in the world—a spa in Poretta, near Pisa and Bologna, which was known as Terme di Poretta. One of our skills was dealing with poison. We used to treat people who had been poisoned with lead by Lucretia Borgia. I then moved on in my commercial and banking world to find that the staff and serpent came from Egypt, where, of course, they treated with waters, and I learnt a lot about Prince Helwan and the others. We ended up financing and building a hospital in Egypt.
	More recently, and with some regret, I have been a director of a construction company that has built 20 hospitals, with more than 2,000 beds. But we have lost so much money building hospitals that we have decided to stop building. I have found that other people have done the same. One great contractor, who shall be nameless, was reported to have lost £100 million on a recent PFI project. You do not knock the health service. I now regard it not as a service but as an absolutely essential public utility. It is a utility, and it becomes more and more essential as, to the regret of many life insurances companies, we live longer and longer.
	I ask why 18 per cent of our utilities in this country are now owned by the Germans and much else by the French, and why we, who had some of the best run utilities in the world, have lost the way. I always felt that the gas man or the electricity man was one of the most knowledgeable people you could meet. Now, the bureaucracy that they face causes us concern. So when we talk about the efficiency of the health service today, I would not talk about the past, as the noble Lord, Lord Bilston, did, I would ask what other people do. I take as an example the health system in France, which I think is the best in the world, and which has 400,000 beds with 500,000 staff. Germany was not so bad, with 500,000 beds and 800,000 people. But in this country, with fewer than 200,000 beds, we are proud to have more than 1 million staff. Somehow, that is where the problem lies. But why should that be so important? We say with pride, "Look at the number of people within the health service". There are good people who are effectively thwarted by levels of bureaucracy and tiers that I find difficult to understand.
	I found out the other day that we also have higher rates of pay for doctors than almost anywhere in Europe. Doctors want to come here because they will receive a higher net income than in their own countries. But they also want to come for some of the technological advances that we have in certain sectors, which included, for a while, new drugs. But the worries when people are doing animal testing and so on makes one realise that many drug companies may now cease or wish to withdraw.
	I do not know what I would do if I was a Minister. I support the whole concept of the National Health Service, but it is extraordinarily difficult to determine how we can resolve this serious problem. In my days as a consultant I had a senior partner who was brilliant at selling himself. He would go to see a company and say, "I have been looking at your shares old chap. They have not been performing. The City does not understand you". There would be an immediate nod of acceptance. Then he would say, "I think that your problem is management". He would be addressing the managing director, who you could watch start to shudder and look nervous. Then my senior partner would add the word, "structure". The problem facing the National Health Service is not people or competence but entirely one of structure.

Baroness Barker: My Lords, I, too, thank the noble Baroness, Lady Cumberlege, for the opportunity to have this debate and for her introduction, which set the scene so well. I also welcome the right reverend Prelate the Bishop of Portsmouth back to your Lordships' House, and I noted what he said about choice. I took it from his speech that what mattered to him was quality of service and that he was not convinced about the extent to which choice was a factor in determining quality, for which I thank him.
	The National Health Service Act 1946 sets out a vision of a,
	"comprehensive health service designed to secure improvement in the physical and mental health of people",
	and,
	"the prevention, diagnosis and treatment of illness".
	That vision remains at the heart of NHS policy. It is as apt today as it was then, even though the context in which the NHS operates has changed dramatically—not least in terms of longevity. However, things have changed in the NHS. In 1948, a consultant was a medical god who attained the right to call himself "Mister". Now, a consultant is someone who appears from the DoH financial turnaround team to tell you what you are doing wrong in the management of your trust.
	Several noble Lords have focused on the fact that increased expenditure has not been remarkable for increasing health promotion or prevention of illness; during the past eight years, it has tended to be in pursuit of political targets. It is against that background that we need to assess the long-awaited White Paper. I shall focus on a few areas of importance. One key factor is the stated aim of rebalancing the NHS in terms of preventative and community care. The Wanless reports give the economic background to the White Paper. They set out in great detail the economic impact on the NHS of failing to invest in social and community care. It is now accepted that failure to do so sets up high costs down the line for the NHS. That is the rhetoric of the White Paper. But the noble Baroness, Lady Murphy, had it absolutely right when she talked about mental health and the reality of how the White Paper downplays small-scale interventions for people who suffer from mental health problems.
	The White Paper's emphasis on integration of the commissioning of health and social care is to be lauded. By 2008, all PCTs—the ones that are left—and local authorities—wherever they are—will establish joint health and social care teams to help people with long-term conditions. That will be an enormous challenge. As noble Lords have said, whatever the structures may be—we do not know what they will be—we will have to merge two entirely different systems; that is, an NHS system, which is based on capacity, and a social care system, which is based on eligibility. Nowhere in the structure has that key issue been addressed.
	I want to concentrate on the cost of reform to the NHS, which is not so much reform as constant churn and disorganisation. One of the costs of reform, periodic as it is, is how it limits the ability of the NHS to deal with other agencies, such as local authorities and schools, all of which have a profound impact on public health. But the principal cost of reform is on the greatest asset of the NHS—its staff. The letter of 28 July 2005 from Sir Nigel Crisp did more to damage the morale of staff in the NHS than can be imagined. I do not know any other leader of a major business who would do that to his staff.
	Another cost, which has not been mentioned today, is the haemorrhaging of expertise from the NHS. The average expectancy for a senior executive to be in post in the NHS or a PCT is reckoned to be two to three years, which represents a massive loss of investment, because the NHS invests well in staff training. That is exemplified in one paragraph towards the end of the White Paper. It made my heart sink. It said that over the next year, NHS staff will spend time mapping local statutory and independent services.
	I have a way to save the NHS money. I know how people can do that in an afternoon. They find the dust-covered filing cabinet in someone's office. They take out the five mapping exercises that were done in the past. They look at them. Then they ask the voluntary sector to help them update the files and to fill in the gaps. There is a massive amount of expenditure in the NHS on unnecessary repetition because of a loss of corporate memory in the process of change. We should recognise that.
	On NICE, I listened very closely to the noble Baroness, Lady Morgan of Drefelin. It has always been noted, particularly in the Wanless reports, that judgments about what is clinically and cost effective are complex and difficult. They are becoming more so as the pace of medical advance increases. But if, in the midst of all this reform, we do not maintain an independent, objective means of determining which drugs work, or not, whatever edifice is built around it, the NHS and medicine will suffer. Judgments need to be transparent and evidence-based. Findings need to be included in NSFs.
	The recent case concerning Herceptin was interesting. I do not blame in any way patient groups who do what they believe to be the best for people for whom they care deeply. But politicians should accept what NICE says and that there will be differences in availability and in prescribing. That is a political difficulty. Ministers should stand behind NICE and give it their support, not use it as a shield.
	Practice-based commissioning is a very interesting concept. GPs are perhaps one of the most stable parts of the NHS. They stay in an area, which they get to know very well.
	People in the voluntary sector, where I work, are most interested in what the potential for practice-based commissioning is. First, it is practice-based commissioning, not just GPs but all staff in practices need to be involved. Secondly, it has to be placed in a context where there is overall strategic planning for the health needs of an area. It is not clear from what is proposed whether patients who are expensive and complicated—such as those with HIV, as the noble Lord, Lord Fowler, revealed—will still have the same access to GPs, or whether they will become too hot to handle. It is also not clear what will happen to specialist commissioning for some of the conditions mentioned earlier, such as diabetes and particularly neurological conditions. What will happen to that?
	Finally, what is going to happen about the overview of scrutiny of health provision in an area? There is an odd section in the White Paper that talks about calls for local action. On theses Benches we believe that it is right to go in the broad direction of the integration of health and social care, but there should be local control, which should be open, democratic and accountable. It should, as the noble Baroness, Lady Murphy, said, include clinicians—much more than it has done in the past—to ensure that choices are well-informed choices. I am pleased to see the emphasis on public health in the White Paper but I do not see how that can be fulfilled, especially, as was said at the time, when local government is about to be reorganised.
	However we do it, we need a system in this country which brings out the best of local knowledge of acknowledgement which has behind it overarching skills, the research that we have talked about has been so necessary and above all else enables patients to know how and when they can influence the provision and work with the clinicians as the noble Baroness, Lady Murphy, said.
	The White Paper holds out some prospects. Whether the resources are there to make it a reality is something on which the jury is going to be out for a considerable time.

Earl Howe: My Lords, my noble friend Lady Cumberlege is to be congratulated on having tabled this Motion and on introducing it so superbly. I am sure we all agree that we have listened to some excellent speeches throughout this debate. I join my noble friend in thanking the noble Lord, Lord Warner, for changing his diary arrangements in order to be present to reply.
	Some four years ago the Government did something bold and important and right, which was to start thinking seriously about how to put the patient at the centre of decision-making in the NHS; how to empower the patient; and how to give the patient a greater choice over what happens to him. In a state-run monopoly such as the NHS that somewhat revolutionary thought entailed certain consequences. It meant setting up payment mechanisms so as to enable money to follow the patient in response to the choices the patient made—the system known as "payment by results". But it also meant giving hospitals a greater ability to compete for the patient's favour and to be more responsive to local health needs. That, in turn, involved something pretty revolutionary, which was the idea of setting hospitals free of the shackles of central government control. Hence the foundation trust was born; and hence, to create greater capacity in the system, independent sector providers were brought in to take some of the load off the NHS—something that in May 1997 would have been inconceivable.
	At the same time as all this, the Government did something else that was important and right, which was to address the problem of recruitment and retention in general practice; in the medical specialties; and in nursing and midwifery. Patient choice is not deliverable without doctors and nurses on the ground to deliver it. New contracts were negotiated with all three groups, the net result of which, in each case, was a very considerable increase in basic remuneration. Into the melting pot at the same time as all this was thrown another good idea: that at general practice level GPs should be able to commission services on behalf of their patients. Practice-based commissioning is not the same thing as the old fund-holding, alas, but it strives to achieve what fundholding did, which was to give real choice to patients and to make the health service more responsive to what patients need.
	If three years ago you had presented these reforms to a bank manager in the form of a business plan, there is one thing you would have been told, which is that every single one of these changes is potentially destabilising to the NHS. So when you budget for what it is all going to cost, you need to build in a healthy margin of safety to allow for the unexpected; and, as my noble friend Lord Fowler rightly said, you need to have high quality management to steer the reforms through what are very probably going to be some choppy waters. The Government would have done well to commission and heed such advice. They did not. And because they did not, it is not wrong to say that the NHS currently faces an almost unprecedented degree of uncertainty and instability, with inevitable knock-on effects for patients.
	The large deficits we are now seeing are only part of the issue. The Minister is right to remind us, as he does, that as a proportion of the NHS budget the current deficit is not the highest it has ever been. But what is different today is that at trust level, there is now absolutely no give in the system. Many NHS trusts—possibly the majority—are having to cut back services; the reason for that is, quite simply, that the Department of Health got its sums wrong. The GP contract, the consultants contract and Agenda for Change were imposed on the NHS from the centre and are all costing a great deal more than the Department budgeted. With the activity targets imposed on them, trusts have effectively had no room for manoeuvre. Worse still, as the noble Baroness, Lady Murphy, mentioned, these pay contracts contained almost no incentives to increase productivity, so that hospitals are being forced to save money in other ways that are extremely painful. But on top of that, the tariff system under payment by results is still immature. In a survey of PCTs and GP practices last month, 93 per cent of respondents said that the payment by results system was unfit for purpose and needs amending. Their chief criticism was that it encourages so-called gaming by providers to maximise income unfairly.
	It is no tribute to the department that last week, only three weeks after publishing the national tariff for next year, they suddenly withdrew it and, in so doing, threw the business plans of the entire health service into a state of complete chaos. Simultaneously with that, leaders of PCTs were being told that their careers hung in the balance if they failed to produce improved financial forecasts within days.
	We are witnessing departmental mismanagement on an epic scale Financial control of the NHS has effectively been lost. But there is a whole separate dimension to this. Last December the Government announced a major reconfiguration of NHS bodies. The number of strategic health authorities is to be cut from 28 to between nine and 11; and the number of PCT's cut by nearly two-thirds from 302 to a minimum of 115. This reconfiguration comes only three years after the last one; when, noble Lords will remember, the Government abolished the 100 health authorities, along with the nine regional offices of the NHS Executive. In other words, we are going back, after only three years, to almost exactly the same configuration of NHS bodies as we had before. The cost of this reorganisation in redundancy payments alone will be £320 million.
	The reason given is that it will save the NHS £250 million a year. Whether it will or not remains to be seen, but it is not just the upheaval that this will bring. The Government are also proposing major changes to the structure of PCTs without first clearly defining what their role should be. Originally, Sir Nigel Crisp said that PCTs would become "commissioning-led" organisations with only a minimal role as providers. That was Government policy. The Secretary of State then contradicted him and said that it would be up to PCTs whether they continued to provide services. That inexcusable muddying of the waters prompted a broadside from the Health Select Committee in another place. The whole impression given is of policy-making on the hoof from the centre. Indeed, the public consultation exercise that took place last year might just as well not have happened.
	The effect of all this on the workforce in PCTs has been deeply demoralising. It is a huge distraction from what really matters, which is delivering community services and public health services to patients and setting about the important task of implementing the recent White Paper. And for strategic health authorities, the task is formidable. How do you start to design new organisations unless you clearly understand what their function is going to be? How do you know if PCTs are going to be fit for purpose if that purpose is left open? And if, as a senior manager in a strategic health authority you know that your own job may not exist in a year's time, what does that say about your eventual accountability for the decisions that you take?
	The Minister may be able to see his way out of all this, but from where I sit, we are looking at very serious central management failings that sit alongside, I am sorry to say, equally serious political misjudgments. The recent White Paper opens up some good and worthwhile policy ideas, but I say to the Minister something very simple. Let those ideas not be ruined by core planning. The White Paper is not anything like costed, a point made very powerfully by the noble Baroness, Lady Murphy, in her speech. The last thing we want is for services to move into the community, only then to be found to be unaffordable. Unless there is proper planning, moving services from the acute sector has the potential to destabilise NHS hospitals even further. That must not be allowed to happen. We must acknowledge that on top of all the other policy initiatives in the health service, the White Paper carries risks.
	Over the next few weeks we need to see one thing: that Ministers have a plan to instil, contrary to all appearances, a sense of internal consistency and coherence into health policy. It is a tragedy for the NHS and for patients that that sense of coherence is now so noticeably absent.

Lord Warner: My Lords, if the noble Lord were to wait patiently, he would hear the rest of the story. I hope that he will wait patiently while the rest of the story is unfolded for him.
	We have put up spending from £34 billion a year in 1997 to £90 billion by 2008. There are 27,000 more doctors and 79,000 more nurses since 1997. I hope that no one on the Benches opposite is suggesting that patient care can be improved without having more doctors and nurses. Waiting lists are at their lowest point ever. Since last month, no patient has been waiting longer than six months for their operation, with the average wait now about eight weeks. These are some of the results that have been produced by the extra investment. Some 99 per cent of people with suspected cancer are seen by a specialist within two weeks of referral by their GP, and since 1999 we have recruited nearly 1,000 extra cancer consultants. Patients now have a choice of four hospitals or clinics for their elective surgery; early deaths from cancer are down by 14 per cent, and for coronary heart disease they are down by 31 per cent. These death rates, along with the suicide rate, continue to fall.
	I suspect that if you were to ask most of those in the population who are affected by these conditions, they would say they think that they have had rather good value for money in the service improvements that have been made. We have 138 new or modernised hospitals after many years of under-investment, and there are many areas in which we have put in new equipment. We have, for example, 1,200 new pieces of modern equipment purchased over the past five years to help consultants in cancer save more lives. These are some very specific numbers to show where the money has gone. Patients no longer have to wait hours to be seen in A&E departments. In fact, 98 per cent of patients are now seen within four hours. Ambulance services are reaching 75 per cent of potentially life-threatening emergencies within eight minutes. Amid all this, as I have said, waiting lists continue to fall.
	Other major killer diseases have been tackled more effectively, and as I have said, premature deaths from heart disease, stroke and related diseases have continued to fall. If this was not already impressive enough, we have also worked to narrow health inequalities. I do not remember health inequalities being featured that strongly by the party opposite when it was in office. Health inequalities have been closing at a rate of more than 2.5 per cent in less than half a generation. In essence, that means that services are reaching everyone in society, including those who need the most but in the past might have struggled to gain adequate and appropriate access. Patients and carers now have many more ways to receive and provide advice and help without needing to use traditional NHS services. Notable examples of offering care and advice at a time and in a way that patients need are NHS walk-in centres and the NHS Direct telephone service and website. These are just two examples of new ways to help people get more and quicker access to services and advice.
	A number of noble Lords have talked about efficiency. Anyone would think that there have been no improvements in efficiency under this Government. The average hospital stay in England decreased from 7.4 to 7.1 days last year, delayed discharges have fallen by more than 60 per cent. in the past four years, management costs are down from 5 per cent to 4 per cent in the past seven years, and cancelled operations continue to decline. It is not just me and other Ministers saying this—these developments and improvements have been recognised by others. The Healthcare Commission, in its report, The State of Healthcare, commented that,
	"much should be celebrated . . . people are now able to gain access to many services more quickly and easily than in the past . . . long waits for hospital care have largely been eliminated".
	That is an independent body looking at the evidence available.
	However, I recognise the realities that a number of noble Lords have brought to the debate. I pay tribute to the noble Baroness, Lady Murphy, for the way in which she has contributed to the NHS, and I congratulate her, in her capacity as chairman of a strategic health authority, onr bringing her budget in on balance, with good-quality services provided across east London. We recognise that some areas of the NHS still need to improve. In 2004–05, the NHS ended the financial year in deficit for the first time since The NHS Plan was published. As I have said, that needs to be put in historical perspective.
	In the current perspective, however, the majority of NHS organisations are delivering good services, with service improvements, and living within their budget, as the noble Baroness, Lady Murphy, explained. The concerns are in a minority of organisations, and we are taking action with the under-performing organisations to ensure that financial balance in the NHS is achieved by the end of 2006–07. We will say more about some of these issues at a later stage. The Department of Health has put in place a comprehensive programme to work towards rectifying financial mismanagement problems in that minority of trusts experiencing difficulties.
	I recognise the upset and frustration caused to the NHS by the errors in the 2006–07 tariff, under payment by results, which a number of noble Lords have mentioned. As the Minister overseeing this area, I apologise unreservedly for the technical errors identified. We are trying to put those right. We will work with the NHS to test revisions as quickly as possible, to get a seriously good assurance that the revised tariff will be correct and will enable people within the NHS to get on with their financial planning. I must acknowledge that we should have done better in that area.
	What of the future? Several noble Lords have mentioned our new White Paper, Our Health, Our Care, Our Say produced after a major public consultation. One of my best experiences as a Health Minister was spending a Saturday with 1,000 people in Birmingham listening to what they had to say about their health priorities and what they wanted to see from the public services that they were funding. It is absolutely clear that the messages encapsulated in that White Paper were the messages that people were giving to us. This White Paper was not dreamt up in Richmond House; it responds to and reflects the views that people have put to us. They want to see more services closer to home, more services not in hospital, local government and the health service joining up work together more effectively, and more effort put into health promotion and prevention. They accept that they should have more responsibility in terms of self-care, but they want the public services to provide more support to help them do it, and more support for the people caring for them. We have a journey to travel, but it is one set by the people of this country, not just by the Government.
	Several noble Lords have mentioned some of the changes introduced by the Government. I am grateful to the noble Earl, Lord Howe, for his recognition of the improved change of direction that we have been trying to introduce in relation to plurality of providers, more choice in the system and practice-based commissioning. I share his views that practice-based commissioning will make a real difference to the more personalised and appropriate services that patients will get. There is clinical buy-in. I acknowledge that we might have worked harder on selling to, persuading and working with general practitioners in this area. In the past year or so, however, we have put a lot of effort into working with the profession, and we have got considerable buy-in. This is a direction of travel that they want to see.
	We have had some criticism for the introduction of independent sector treatment centres, but not, I was pleased to see, from the Benches opposite. These centres have already cut waits for diagnostic treatments and elective surgery for 250,000 people with a relatively small proportion of the NHS budget. They have caused parts of the NHS to reflect on their own clinical practices and the way that they provide care services to patients. That is a good innovation. We are still strongly committed to moving down the path of hospitals becoming foundation trusts. They have to have their finances in good order to do that, for the kinds of reasons that several noble Lords have mentioned. We are not taking our foot of the accelerator in that area, however, and I have recently sent another 20 or so candidates for foundation trust status to Monitor, and we have a programme to continue that in the coming months. I cannot respond to all the points made by noble Lords, but I promise to go through Hansard carefully and to write to all noble Lords on all the detailed points and concerns that they expressed. I hope to be able to say yes to my noble friend Lord Stone about speaking at his conference.
	I must respond to and correct one issue, which relates to the concerns expressed by the noble Baroness, Lady Cumberlege, about computerised applications for doctors under the new system of modernising medical careers. I freely acknowledge that there is an online application process. It is, however, marked by experienced doctors from the postgraduate deaneries. Computers have no say in that process. It is a fair, open and transparent process and provides a single gateway for all applicants and helps practitioners match applicants to vacancies. I have already written to The Times, which published today a letter rebutting the erroneous set of statements previously published.
	In conclusion, our strategy of investment and reform was always going to have some bumpy periods because of the scale of our ambition to improve the health and social care system for all our fellow citizens. My noble friends have rightly paid tribute to the considerable advances that we have made in the NHS. Those advances are also a reflection of the huge investment of effort by NHS staff of all grades who have committed themselves to improving and turning round the NHS. We have to keep our nerve. I accept that things in some cases could have been done better, but that could be said of all governments. All governments could do things better with hindsight—hindsight is a wonderful thing—and I freely acknowledge that we have made some mistakes, but the direction of travel is right. We have hugely improved the services for people living in this country.
	I finish by paying tribute to all that the NHS staff themselves have done—if I may put it this way—to rescue the NHS from the years of neglect under our predecessors. Working in partnership with doctors, nurses, allied health professionals, porters, cleaners, catering staff, managers and non-executives, we will come through this difficult patch. We will ensure that the NHS continues to improve and meets what I recognise are the understandable rising expectations of our fellow citizens. At the core of our debate are the needs of patients and carers, and it is on those that we all need to focus and make sure that we can make their lives better.

Lord Goodlad: rose to call attention to the value of the voluntary sector and volunteering; and to move for Papers.
	My Lords, the debate is of relevance to a large number of organisations and our fellow citizens. That number has expanded enormously in recent years. The National Council for Voluntary Organisations estimates that in 1991 there were 98,000 general charities, with a combined expenditure of £11.2 billion. Ten years later, in 2001, there were over 153,000 general UK charities, with a total income of around £20 billion—nearly twice as much. The 2003 Home Office citizenship survey estimates that 42 per cent of the population of England and Wales volunteered formally at least once in 2002, volunteering being defined as,
	"giving unpaid help through groups, clubs and organisations to benefit other people or the environment".
	The voluntary sector encompasses organisations of differing scales and purposes—large charities such as Oxfam, Save the Children and Barnardo's employing thousands, and smaller community-based groups having no paid staff. Causes include sport and recreation, estimated by the Central Council for Physical Recreation to represent 26 per cent of all volunteering effort in Britain, health and social welfare, the arts, the environment, education and many other purposes both at home and overseas.
	The depth and breadth of the national experience is strongly represented in your Lordships' House, as witnessed by those present at this debate. I have no current interest to declare, but confess to having worked as a Voluntary Service Overseas volunteer as an auxiliary housemaster at St George's Home for Boys in Johannesburg some 45 years ago. My noble friend Lord Skelmersdale is also a return volunteer from Zambia, as is the noble Lord, Lord Filkin, from Ghana. I notice that VSO's interest in the other place is represented by Mike Gapes, chairman of the Foreign Affairs Committee, who was a VSO volunteer in Swaziland in 1971 and will be well equipped by that experience to deal with the Permanent Under-Secretary of State at the Foreign and Commonwealth Office, Sir Michael Jay—VSO Zambia, 1967—and the Director-General of the British Council, Sir David Green—VSO Pakistan, 1967. Should Mike Gapes wish to take his committee on an overseas visit, I am sure that his influence with the Chief Whip, Hilary Armstrong—VSO Kenya, 1967—and assistant government Whips Tony Cunningham—VSO Tanzania, 1980—and Gillian Merron—VSO Guyana, 2005—will ensure that he receives a typically caring Whips' Office response.
	VSO, like most charities, has changed enormously since it was founded 48 years ago, when enthusiasm and energy were the chief qualifications. The average age of volunteers has increased enormously. I met in Cambodia some years ago a married couple in their late 60s, recently retired from general practice in this country, who were VSO volunteers running a large hospital. Volunteers are now much more highly qualified and VSO is by far the largest organisation of its type in the world.
	The vastly expanded voluntary sector, with an income of £26.3 billion and an operating expenditure of £24.9 billion, has assets of £66 billion and a paid workforce of at least 600,000—over 2 per cent of the overall paid workforce of the UK adult population. Twenty million people volunteer formally at least once a year and 13 million at least once a month. Most people's lives in this country are now touched by the voluntary sector.
	Something has been happening in our country, as we see around us in our daily lives. As Martin Birchall, editor of The Times Top 100 Graduate Employers has pointed out, three-quarters of students who left UK universities last summer said that they hoped that their first job would let them,
	"give something back to the community".
	Stuart Etherington, the chief executive of the NCVO, wrote in The Guardian in February:
	"It seems we have entered some kind of voluntary sector 'perfect storm' where everything, at least in terms of the rhetoric, places us at the centre of policy making in this country".
	The Government have responded to that with the compact of 1998, the cross-cutting review of 2002, the Russell commission last year and the Charities Bill. The "Year of the Volunteer 2005" has come to an end. It would be interesting to hear from the noble Baroness, Lady Andrews, how far its aims—to increase the number of volunteers, particularly from marginalised groups and the young; to open up more volunteering opportunities in the public and voluntary sector; and to raise the profile of the work that volunteers are doing—have been achieved.
	Last week, the Public Accounts Committee in the other place produced its 32nd report, Working with the Voluntary Sector. The report concluded that the Government had failed to meet key targets to increase the voluntary sector's involvement in public services. Will the Minister anticipate the Government's formal response to the report by telling your Lordships the Government's thinking on how the targets can be better implemented in the future?
	What problems does the voluntary sector find are hampering its activities? How can its efforts be more greatly empowered? The Better Regulation Task Force has recommended a review of VAT on charities and of the rules that apply to charities' trading arms. Sir David Arculus, the task force chairman, in referring to red tape tying the sector in knots, says that what the sector needs is a level playing field, no more and no less. Irrecoverable VAT costs charities £400 million to £500 million a year, according to the estimates, all of which is to be paid from donations made by donors. As one Royal National Lifeboat Institution volunteer expressed it recently:
	"When the RNLI spends money to provide this service, with money that has been generously donated, it pays £3.2 million in VAT that it cannot recover. This is not what we risk our lives for. RNLI volunteers give their all. Surely it is time for the Government to give back to our charities what belongs to our charities".
	Not surprisingly, the financial burden of irrecoverable VAT on charities and its consequences for their work is unpopular with the public. A MORI poll last autumn showed that eight out of 10 people believed that charities should be compensated in full for irrecoverable VAT. The Charities Tax Reform Group, supported by all the major umbrella organisations in the sector, is seeking to persuade the Government to compensate charities for the irrecoverable VAT that they incur in four priority areas where a matching grant system is most needed.
	The first area is VAT on social welfare service, where charities are complementing or substituting for state provision. This would give charities parity with other service providers such as local authorities and ensure that there was no discrimination or distortion of competition. The second area is VAT on fundraising—the Government have urged charities to make use of tax incentives to encourage charitable donations, but penalise most heavily those charities working hardest to raise funds to meet their charitable objectives. In 2003–04, Oxfam spent £18.9 million in fundraising and lost £1.3 million through irrecoverable VAT in the process.
	The third area is joint ventures and shared services. The Government have actively encouraged charities to work together and to share costs and services, but the VAT system penalises those that do. When one charity offers a service to another, it has to charge VAT on the supply, but the charity paying for the service cannot recover the VAT. That is a further example of the absence of a level playing field between the charitable sector and the public or commercial sector, where sharing services is the normal method of reducing support costs. The fourth area is the repair, construction and maintenance of social welfare housing and charitable buildings. Currently, charities face a large and unfair problem of VAT, while public sector providers are VAT exempt and private providers can recover the VAT that they incur. Charities have the worst of both worlds. They can compete for contracts, but not on an equal basis with their competitors, resulting in lower-quality public services.
	Government officials have acknowledged that charities are almost uniquely penalised by the VAT system, because they provide a mix of fully taxable business supplies, exempt business supplies and non-business supplies. The administration involved in calculating which bit of VAT relates to which service is complicated and onerous, particularly for small organisations. Commercial organisations providing services do not have a problem recovering the VAT, as they almost exclusively provide taxable services. Local authorities receive an automatic refund of the VAT that they pay on providing services, many of which are identical to those provided by charities. Other member states of the EU have put in place mechanisms for reimbursing all charities some or all of the VAT that they have been charged; such schemes are compatible with EU legislation but of course are a national budget decision. I hope that the Minister can assure us that the Government is treating this problem with urgent sympathy.
	Other issues that concern the sector include the legal definition of a volunteer, which has been the subject of recent litigation. Clarification of the law would be desirable. The CCPR, for example, advocates the development of an agreed definition of a volunteer, enabling them to be covered under such laws as health and safety legislation but not giving them the same legal status as employees. Risk and insurance are also of concern to the sector. Volunteering England is now carrying forward work to address these issues. The Compensation Bill now before the House is of relevance.
	Changing times need new ideas. An important new initiative has been the founding in December 2005 by David Cameron of the Social Justice Policy Group, under the chairmanship of Iain Duncan Smith, which is charged with looking at ways of empowering the voluntary sector, fostering social enterprise and encouraging neighbourhood revival.
	Possible ways that are being studied of encouraging the social sector's expansion include simplifying the complicated and fragmented flows of funding in the charity and voluntary sector; relaxing rules in the tax and benefits system and rewarding volunteer work; offering long-term contracts for the provision of services, so that the voluntary sector can grow; changing planning rules to make it easier for the voluntary sector to use space flexibly and create new facilities while respecting concerns of local residents; creating a level playing field in the awarding of contracts for the delivery of social service at the community level; and introducing a national school-leavers programme to prepare teenagers for their responsibilities as adult citizens and to teach them about life in different communities. In addition, there is the idea of creating new social enterprise zones, where social enterprises—businesses that trade with a social purpose, such as the Big Issue, estimated to contribute more than £18 billion a year to our economy and to employ around half a million people—charities and volunteer organisations can thrive. All power, say I, to the elbow of the Social Justice Policy Group.
	The tide of charitable activity, volunteering and the voluntary sector is a swelling current, which no doubt has many tributaries: the failure of the state and the private sector over the past 50 years to tackle the increasing gap between rich and poor, both at home and abroad, and to successfully address some of our communities' long-term needs, such as multi-generational unemployment, drug and alcohol abuse, and a sense of spiritual poverty; awareness of need as a result of the development of mass communication; and greater leisure enabling people to put something back into the pot. Who knows what the variety of these tributaries is? What is certain is that voluntary action is now an essential part of the fabric of our society and economy. It is a vital expression of community spirit, duty, compassion and personal responsibility, where people act on their own priorities independent of the state. That tide is flowing now as strongly as it ever has. Your Lordships' House has been and remains an important part of that tide, hence this debate. I beg to move for Papers.

Lord Addington: My Lords, I thank the noble Lord, Lord Goodlad, for bringing this debate to our attention. I speak about volunteering from the point of view of someone involved in the sports world. It was a revelation to many who take part in sport that if you coached, you were a volunteer. The Government either had great political cunning or great wisdom in drawing that matter to our attention, because the sporting world had not addressed it. We were coaches supporting players, like touch judges. We did not regard ourselves as part of a bigger family, but we are. We are giving our time for free to support sporting activities, especially at the junior level, which comprises the vast majority of sport.
	The debate about sport and physical recreation continues apace—I refer to the 2012 Olympics and the debate about obesity. To put it more flamboyantly, the fit people and the fat people have got together to concentrate minds wonderfully well on how important sporting activity and physical recreation are to the nation. This large part of the volunteering world comprises a support service to the organised state service. All the political parties seek to raise standards in sport and to promote sporting activities after school, which has to be done primarily through the link between voluntary amateur clubs and schools. I favour the definition of a sport primarily conducted through clubs with support services from schools. Others would put the emphasis slightly more differently. Clubs are important because they provide the link once you are not prescribed to do a sport. You are not in a structure that tells you to do it, thus the volunteering angle comes in.
	One of the main considerations in the modern world is how best to prepare people through qualifications to fulfil the volunteering role. The recent trend away from adult qualifications in further education, or at least talk about it, means that people are getting worried. Coaching qualifications, which are important for safety and merely being up to date in your sport, take time and cost money. Will the Government assure us that it will become a key requirement for further education to provide such training for these groups?
	Much will be said about school teachers getting extra help and extra qualification, but they are not a big enough pool to ensure that we have people who are trained properly to ensure health and safety and the enjoyment and development of sport. Unless people are trained properly, they do not tend to enjoy sport because they are generally being told the easiest way to play a game. If you know how to catch, pass or kick a ball in any sport but cannot do it properly, you do not enjoy yourself. If you do not enjoy yourself, you stop doing it at the first available opportunity—unless you have a masochistic streak running through you. We must try to make sure that such volunteers—this great bonus and support to the health service—have qualifications. The sporting world is very worried about much of what has been said of late about work-based employment and further education being the main thrust of training.
	Another related issue is the risk of litigation and the compensation culture that we hear so much about. It will be no surprise to anyone who has heard me speak before that my sport is rugby. In rugby, the odd bump, bruise and even break is accepted as part of a contact sport. I think I hear a celebratory, "Hear, hear" from my noble friend. That might be slightly overdoing it, as he cannot put his full weight on his left knee at the moment. The risk of the odd bump and bang is much better than carrying two or three stone around your waist in excess fat. It does not do you as much harm to have the healing process operating as it does to be obese. Will the Government assure us that they will take every opportunity to ensure that people are told not to sue over ordinary sporting injuries? You should not go on about it, especially if you have been correctly trained and coached in the first place. If the Government can make that statement clear and enforce it in legislation—we will shortly have an opportunity to make that happen in legislation—we would all be much happier.
	I now come to a specific point and question as a result of my consultations with the CCPR about the effects of the Private Security Industry Act 2001, which created the Security Industry Authority. It means that stewards and people on bars are properly trained as bouncers. I appreciate that the people who briefed me have an axe to grind. The problem has arisen from the fact that sporting events such as the Wimbledon tennis championship and Badminton must have their voluntary stewards trained to the same standard as doormen and bouncers. I appreciate that the securities industry might have a different take on this. The Act was designed to cut down criminality among gangs who were effectively operating protection rackets around doormen services in parts of London. Is it appropriate that that is applied to certain events merely because they have a beer tent? If so, at what level should it be appropriate? I appreciate that the Minister might not have an answer for me now, but he can let me know over the course of time. More information would be appreciated.
	Will the Minister assure me that this legislation is not merely catching the wrong group or being badly applied? Once again there is a great deal of fear that extra costs for training will stop probably the most pure form of volunteer—people who volunteer to steward for a few days a week at an event—who will have to go through expensive training that will up the costs and might endanger some of these sporting events. I hope that the Minister will be able to answer me in due course.

Baroness Emerton: My Lords, I, too, thank the noble Lord, Lord Goodlad, for raising this debate on the voluntary sector and volunteering. I declare an interest, since I became a volunteer at the age of 11, as a St John Ambulance cadet, and worked my way through to being the chancellor and chief commander, retiring in 2002. I am also involved in other charities, and am chairman of the National Association of Hospital & Community Friends, and the Defence Medical Welfare Service.
	It has barely been two months since the end of the Year of the Volunteer, and I am sure, as has already been mentioned, that we would like to commend the initiative, energy and enthusiasm which it has delivered. I look forward to hearing details from the Minister. Only last week, the Chancellor of the Exchequer, the right honourable Gordon Brown, officially launched the country's first national youth volunteering service. Certainly, volunteering seems to have achieved an unprecedented profile and there has recently been a proliferation of initiatives.
	However, I would like to take up some of the aspects of health and care volunteering initiatives, particularly relating to the White Paper, Our care, our say: a new direction for community services. Paragraph 7.96 says:
	"The third sector, together with the private sector, already provides over 70 per cent of social care. However, there are currently considerable barriers to entry for the third sector in providing NHS services. If we are to utilise the expertise of third-sector providers, we need to lower these barriers".
	It is good to know that the Government recognise that there are barriers. There are also good examples of where those barriers are being lifted. For example, picking up from the noble Baroness, Lady Morgan, the introduction of Compact in 2004 provided the opportunity of formalising and developing partnerships and has been successful in many areas and organisations, but there are still some difficulties.
	I am privileged to chair a working group, making partnerships work for mental health under the auspices of the National Institute of Mental Health for England. There is a group of NHS and third sector representatives. We have worked at developing a strategy to present to the national strategic partnership forum as a possible model for areas that require detailed consideration when looking at partnership agreements. There are many good examples of partnership working in mental health and in other areas, but there are also many experiencing difficulties.
	There are other barriers that cause frustration. The most recent two, relating to the funding from the Department of Health, are the delays in the allocation of Section 64 and the opportunities for volunteering grants. That caused considerable uncertainty to local organisations, particularly small organisations, having an adverse effect on projects, consequently reflecting adversely on patients and clients.
	The second paragraph in the White Paper to which I would like to refer states,
	"The Department of Health will also establish a fund from April 2007 to provide advice to social entrepreneurs who want to develop new models to deliver health and social care services. This fund will also address the problems of start-up as well as current barriers to entry around access to finance, risk and skills, to develop viable business models. The Department of Health will tender for an organisation to run the fund and provide these services".
	While it is encouraging to know that the Department of Health will establish a fund in 2007, I hope that that will not be to the detriment of Section 64 or the OFV funding. I can speak with experience of the current frustrations relating to a tendering and procurement arrangement. I have experienced it as chairman of the National Association of Hospital and Community Friends. That organisation started life as the League of Friends. I remind the House that it represents 45,000 volunteers and produces £45 million per year, which is put back into health and social care.
	We are now in partnership with NAVSM, so we cover 100,000 volunteers over 1,000 sites. That provides various initiatives through the whole range of social and healthcare institutions and communities. The tendering exercise extended from January to November. It was a single tender. No contract was awarded, taking no account of the time and cost to the headquarters staff. That indicates that government departments should have a better understanding of the workings of a small voluntary organisation with a headquarters staff of only nine.
	The third paragraph states,
	"Under the Civil Contingencies Act 2004, PCTs will retain the responsibility to contribute to multi-agency planning and response in the event of a major incident, whether accidental or intentional. All arrangements for the provision of community services will need to ensure that those services contribute to planning for, and are able to respond to, any major catastrophic incident involving the PCT, including the provision of mutual aid to other organisations with the local health community".
	Here there is no mention of the volunteers or voluntary organisations. I ask the Minister for an assurance that the voluntary aid societies, the British Red Cross and the St John Ambulance, as well as other voluntary organisations, will be invited by the PCTs to participate in the planning not only for major incidents but for public health emergencies such as avian flu.
	In summary, voluntary organisations and volunteers are not solely concerned about raising money. The motivation is about attitudes that support a positive environment and local health and social care services. As registered charities, voluntary organisations are responsible to the Charity Commission for good governance. While developing partnership agreements and entering contracts are important ways forward it is also important to recognise that while the voluntary organisation is responsible and accountable for delivering the content of the contract it is not accountable to the other partner in a managerial sense, but is accountable to the Charity Commission itself for good governance.
	There needs to be a growing understanding between government departments and the third-sector organisations of each other's roles and parameters and a development of mutual trust. That requires a steep learning curve for government departments and the voluntary sector to ensure that health and social care needs in the widest sense are successfully met.

Baroness Greengross: My Lords, I am delighted to take part in this debate and I congratulate the noble Lord, Lord Goodlad. I have spent the past 30 years working, one way or another, in the volunteering and voluntary sector. So, I would like to concentrate partly on the role of older volunteers, in looking at the enormous contribution that volunteers generally make in this country—about 1.8 billion hours every year, with 47 per cent of those hours put in by people aged 50 or over.
	Of course there are huge benefits for those people themselves. We all love the rosy glow. But we also must celebrate the effect on society generally. Most of our voluntary organisations would pack up if it were not for the older volunteers, and a lot of our local communities generally—magistrates, school committees or whatever—would not manage without older people using their experience, knowledge, loyalty and commitment for the benefit of the local community, or, indeed, nationally or internationally.
	I spent many years at Age Concern. I was very fortunate to be able to get a lot of initiatives off the ground, many of which were intergenerational—probably my favourite type of volunteering. The benefit to both ends of the age spectrum made me weep with joy when I was face to face with the initiatives concerned. One of them, Ageing World, was funded across the whole of Europe. At one stage we had 12 countries participating in initiatives in which older, senior health mentors were trained and then gave health messages which encouraged healthy lifestyles, enabled early diagnoses and treatment, and built very successful, healthy alliances across each of the European state partners. That was a really wonderful experience.
	Since becoming a vice-president of Age Concern—of course I keep very much in touch with my former colleagues—I have been involved in volunteering initiatives in other ways too. One of them is the Experience Corps, which I still chair, which for three years was funded by the Government through the Home Office, and which managed to recruit over 200,000 volunteers, all over 50, mostly from ethnic minority and hard-to-reach communities through working through faith groups. They who have done the most extraordinary things. For example, in Derby there were a lot of problems with young Asian kids completely destroying the buses that took them to school every day. Nobody knew what to do about it. Through the Experience Corps, the older parents manned the buses, and, because of the respect for older people in that community, the wrecking of the buses immediately stopped. There is a huge amount like that that can be done for the benefit of the wider community, and which it is really worth celebrating.
	The Experience Corps is still working to introduce ways of consulting with hard-to-reach groups, so that programmes can be designed to meet their particular needs. I am very proud of that. We also should not forget the huge commitment of many of our large and small corporate bodies to provide volunteers. I chair an all-party group on corporate responsibility, and I am very heartened by the hundreds of thousands of volunteers who are in work, but who are given time to work in the local community or to go all over the place, perhaps to work in schools with pupils who need extra help, or sometimes internationally. That has to be encouraged and celebrated as well.
	At an international level, I join the noble Lord, Lord Goodlad, in paying tribute to VSO. I am privileged to be its partner in a small, post-tsunami initiative in Sri Lanka. I admire the work that it does. Our own volunteers, who are going out to share skills that are needed in the rebuilding of life in Sri Lanka, tend to be older people.
	I am also a trustee of HelpAge International. I am amazed by what is achieved through the sort of work that it does—often to the benefit of older people—in many countries all over the developing world. Just yesterday, I was in a meeting in Portcullis House which looked at AIDS work carried out by volunteers. VSO states that it sent 219 skilled professionals to work in HIV and AIDS service last year. It has done the most amazing work in communities, particularly in Africa, where AIDS-related disease has affected people of all ages, including grandparents who are left to bring up children with no support and no resources. The problems that they face are quite amazing, so anything that those volunteers can do is really worth supporting.
	In a 2004 report, Facing the Future Together, the UN called for the recognition of volunteers. Though the report focused mostly on work in HIV and AIDS across the developing world, it applies to our country as much as to any other. We really must recognise volunteers, but try to remove the blocks, particularly in the case of older volunteers, that sometimes mean that they cannot do what they would like to do. There is still a lot of discrimination on the basis of age. That manifests itself, for example, in the impossibility of getting adequate insurance cover. It is mostly based on negative attitudes. People do not recognise that those who are older bring a great deal to the work that they do.
	Last weekend, I went to celebrate the 100th birthday of a woman who was one of the forerunners of counselling, family planning and marriage guidance, as it was then called in this country. At the age of 94, she was making sculptures that went on show in the British Museum. Last year, she was still counselling other people.

Baroness Greengross: Yes, my Lords, I am sure that it is a very good example, but not everybody here is terribly old, so we have to celebrate our younger Members, too, because they give a great deal.
	The lady in question was able at the age of 99 to be a support and help to bereaved women in her community. Last time I had dinner with her, I was commenting on a statement in The Times that morning. She corrected me and said, "Sally, I don't think you interpreted that right". She then quoted other articles from The Guardian and the Independent about the same statement. So I am a great admirer of older people. I hope that we can all celebrate volunteering in its entirety.

Baroness Pitkeathley: My Lords, we are indebted to the noble Lord, Lord Goodlad, for enabling us to celebrate volunteering in this debate. I have worked almost all my life either in or with the voluntary sector. I am president of Volunteering England and of the Community Council for Berkshire. I am vice-president of Carers UK and the Princess Royal Trust for Carers, and I am involved with many other charities. I am also chair of the Futurebuilders Advisory Panel and a member of the Commission on Unclaimed Assets, which is attempting to release unclaimed assets from banks for the benefit of the voluntary sector. I understand that the noble Lord, Lord Best, will speak a little more about that later.
	The wording of the Motion today presents us with a problem, given the limited time. Volunteering and the voluntary sector—the "third", or "voluntary and community" sector, as it is increasingly called—are not actually interchangeable concepts, so there is a dilemma in which one to focus on. I will try to draw out the similarities or common themes rather than focus on the differences between them. One of the most important is that volunteering and the voluntary and community sector are both receiving more attention from the Government than ever before. In 40 years, I have never known the sector to have a higher profile or more support from the Government. That support comes in the form of hard cash, for example the millions of pounds put into Futurebuilders, Capacity Builders, and the Change Up programme, and in legislation, for example the Charities Bill and the commitment given to the charitable sector in the National Lottery Bill currently before your Lordships' House.
	It also comes in recognising the part the sector can play in extending the range and scope of public service delivery. That includes acknowledgement of the unique contribution that the voluntary and community sector can bring to public services in its greater contact with users and end recipients, as my noble friend Lady Morgan has reminded us. Because of that contact it is has the ability to provide services which more readily meet the needs of disadvantaged individuals and communities. Typically, the voluntary and community sector has influenced the way all services are delivered, because of the emphasis placed on user choice and involvement. That was pioneered by the voluntary sector, and is a proud legacy which we have given to the public services. It applies just as much to those organisations which focus on campaigning and advocacy as those which focus on service delivery.
	The Government now recognise that for too long the voluntary sector has not competed on a level playing field for service contracts. That was either because local authorities and others were not keen to engage, or because the terms made it impossible for voluntary organisations, especially the smaller ones, to engage in the procurement process. It is not a level playing field if local authorities do not pay their bills on time, or if commissioners try to drive down prices by basing them on volunteers' contributions, or by not acknowledging that voluntary organisations must have full cost recovery for costs incurred. Many voluntary organisations have been reluctant to engage in robust negotiations, lest the grants they need for other parts of their work are brought into jeopardy.
	The Compact with the sector has already been referred to, and I pay tribute with others to the work of NCVO. It has gone some way to addressing these issues, and Compact Plus will go further. We are making good progress. Futurebuilders, too, is an excellent initiative, focusing on trying to wean voluntary organisations off a grant culture by using development money, loans and investments to encourage more and better provision of service in areas of high social need. Though it is early days, some of the initiatives which it has enabled to get off the ground are truly inspiring. It would be useful for Ministers to visit some of these. I must mention here the commitment of many government Ministers, including the Prime Minister and the Chancellor, to these initiatives. That commitment is important, and it is significant that many more MPs and Ministers than at any time hitherto have direct experience of working in or with the voluntary sector.
	In my role as president of Volunteering England, I am delighted with the high profile now given to the whole issue of volunteering. The Russell commission, focusing on youth volunteering, has shown us the possibilities for young people. I quote from Joe Saxton, director of nfpSynergy:
	"Something as well publicised as the Make Poverty History campaign has shown that young people are interested in the idealism that underpins it . . . Far from being 'born hoodies' as media reports suggest, they are keen to volunteer."
	At the other end of the age scale, we have heard from the noble Baroness, Lady Greengross, about the Experience Corps. There is much more emphasis now on drawing volunteers from as diverse a base as possible.
	I am extremely pleased to say that Volunteering England is shortly to announce the appointment of a commission on the future of volunteering, which will play a central role in considering strategies and policies to ensure that we enable volunteers to benefit from their volunteering, as well as being helped to continue their contribution to communities. We ignore at our peril the willingness of so many people to engage in volunteer activities, whether as trustees, school governors, coaches, good neighbours or whatever. We give a lot of attention to anti-social behaviour, but not nearly enough to the very pro-social behaviour that leads people to give up their time freely.
	I should point out that no one has yet fallen, and I hope that no one will fall, into the trap of considering the almost 6 million carers as being in the volunteer category. They are not volunteers. They are fulfilling that often stressful role for reasons of love, duty or family obligation, not from free choice.
	However, the verdict on volunteering and the voluntary sector is pretty positive. Of course, there are problems. We still have to resolve the public benefit issues in the Charities Bill. There are debates about paying trustees or even volunteers at the level of the minimum wage, which must be addressed and which call into question some of the principles that we as volunteers have long held dear. Far too many local and even national voluntary organisations still struggle with fund-raising and having their grants peremptorily cut. However, on the whole, the story is one of which we as a nation can be very proud.

Lord Brooke of Sutton Mandeville: My Lords, as ever, it is a pleasure to follow the noble Baroness, Lady Pitkeathley, who has just spoken for the second time today. I follow her directly sufficiently often in debates in your Lordships' House that Pitkeathley & Brooke is on its way to becoming an item—not a social item, but opposite ends of an ampersand, like Crosse & Blackwell or Chatto & Windus.
	I congratulate my noble friend Lord Goodlad on both his successes in advocacy: first, on securing the debate; and, secondly, on his launching of it. It is a discriminating choice of subject which can inspire almost a score of speeches stretching into the early evening on an unwhipped Thursday from all corners of your Lordships' House, especially from the Cross Benches.
	I declare an interest, as the protagonist of two CAF trusts, one for lay causes, one for ecclesiastical; and as president of the oldest youth club in the world, this year celebrating its 140th anniversary in a modern building within half a mile of this Palace. Anyone who cares to visit will be welcome.
	My noble friend Lord Goodlad, as befits a member of our party, has chosen a subject with an ancient tradition. In the 18th century, the early rump of our parliamentary party, long in opposition, had relatively few commanding principles, but one of them was opposition to a standing Army, allied to passionate enthusiasm for the militia. The British Beer and Pub Association cannot produce an exhaustive list of British pubs, but the Library of your Lordships' House has provided for me an internet list of 43 pubs devoted to the militia theme. Eleven of them are called the Volunteer Inn—one of them, happily, in the former constituency of my noble friend Lord Goodlad—10 called the Volunteer Arms; another 10 called the Volunteer; five called the Rifle Volunteer or Volunteers; and eight others which claim a single entry.
	I know that list not to be exhaustive, because the Volunteer in Market Lavington in Wiltshire, where I have drunk much ale after village cricket matches, is not on the list. However, the most precisely regimental of the latter individualist group is the Fifth Hants Volunteer Arms in Southsea; probably the most isolated, the Royal Volunteer in Chesterfield; and probably the most lonely, the unique—I say this after the speech of the noble Baroness, Lady Greengross—Old Volunteer in Carlton in Nottinghamshire. Of course, the pub signs are military, but their very longevity and ubiquity help to reinforce the sense of volunteering being a golden thread in our national life.
	As to the substance of the debate, I am not quite sure how far your Lordships' House is allowed to animadvert on tax. As a former Treasury Minister for four years, including Customs and Excise responsibilities, I shall confine myself to saying, in no Eurosceptic spirit, that Brussels is a complication when it comes to VAT. I realise that the Government may thus have little leeway, but the complexity for charities of the VAT rules are Kafkaesque and the financial gurus of charities are not necessarily natural Houdinis.
	The ironic epitome of this was the Duke of Wellington's adage in defending Brussels itself against Bonaparte, which was that his own battle plan was always made of leather, whereas the emperor's was made of iron. One of the problems with the VAT rules is that they tend to be made of iron.
	I shall say a brief word—for this is necessarily a telegraphic debate—about leadership, management and training in the voluntary sector. To be telegraphic, some of those with either management consulting or large-scale retail experience who have held executive positions in the Conservative Party in the past decade have not always demonstrated that they understood the difference between volunteers and a paid workforce.
	Those in your Lordships' House who are concerned with the National Lottery Bill will return to it on Monday. I offer a brief trailer to our debate on Clause 11 in Committee. Its title is "Distributing bodies: publicity". Interestingly, given its title, it is permissive rather than hortatory, let alone mandatory, about what those bodies should do in affording publicity to the causes on which they bestow largesse. I agree that the permissiveness of the clause is a start, but unless the distributing bodies draw creative attention to their popular decisions, they have no amulet against unkind critics when they take an unpopular decision at the risk of turning off the punters. I am not seeking to hold Monday's debate today, but the issue is all the more critical because the Government's statutory capacity in the Bill, to a substantial degree to guide the Big Lottery Fund, means that, as the head of Association of Chief Executives of Voluntary Organisations implied in The Guardian 15 months ago, the Government's powers can increase the size of the target when the cause is unpopular, thus encouraging attack, especially if it is targeted to a significantly under-informed audience. We shall come back to that point on Monday.
	I have a final word about volunteering in youth clubs, derived from my own club's experience. An inner-city youth club gains immensely if it can offer sporting activity. We have a gym for training, which is sufficiently well equipped that we can rent it out during the day. But we have no playing fields, so our 11 football teams are ferried across London to other people's grounds. That is a prime opportunity for volunteers. The routes for public sector funding can come either through Ofsted-guided local authority funding—I was once the DES Youth Service Minister—or through that local authority's leisure arm. We had such complications with the Ofsted route that we were glad to be shifted to the leisure and sporting route within our local authority. But even that runs the risk of the local authority wanting to define us a sports club rather than as a youth club, which, after 140 years, misses the point.
	The mild fuss about the Ofsted route, which we caused at reasonably high levels, may have had a subsequently beneficial effect, although I confess to ignorance about that. But let me identify what the Ofsted deterrent was. If a youth club seeks funding for sport through the Ofsted-ordained route, it will be denied funding for sport purely as recreation but will be afforded it if it can be turned into a learning experience. That means the volunteers, often parents who ferry 11 teams across London for half the year, having to prepare a learning strategy before the match and then mark themselves on it when the game is over. That is not what they literally volunteered for. It makes them feel like bad social workers rather than good volunteers. As an annual attender at our club's prize-giving awards, I cannot speak too highly of the club's total enthusiasm. It is an ideal antidote to inner-city ills, and it is too precious to be hazarded by unimaginative bureaucracy.

Lord Haskel: My Lords, I too congratulate the noble Lord, Lord Goodlad, in moving this Motion. In spite of his concerns, like other noble Lords I think that volunteering and the voluntary sector is something in which we can all take pride and pleasure. It is also a huge topic, so it is right that the noble Lord differentiated between the voluntary sector and volunteering. To me, the voluntary sector implies charities and social enterprises, many professionally led and most with strong messages. The noble Lord, Lord Goodlad, told us that there are some 600,000 paid employees in the voluntary sector. That is larger than major sectors of industry. It is as large as the aircraft, the motor car and truck industries all put together.
	But is this volunteering? Not entirely. I agree with the noble Earl, Lord Sandwich. Volunteering is something rather more personal. Volunteers give of themselves. They are the foot soldiers of voluntary sector. As well as raising money, they manage, organise and help out in their own individual ways. There are 25,000 schools in this country, all of which have about a dozen governors. All are volunteers, personally committed to social and economic development as well as education. But all carry moral and legal obligations, obligations which can have a big impact on their finances, their jobs and their relationships; but more of that later.
	Why do they do it? What is it that people get out of volunteering? The noble Baroness, Lady Greengross, spoke of a "rosy glow". Another answer crossed my desk the other day in a letter I received from Mr Lawrie Siteman, who is standing down after five years as chairman of the Kingston Liberal Synagogue. In his letter he asks: what have I learnt in my five years? His reply: that the world of the volunteer requires tact and diplomacy, a level of sales skill, a high degree of communication skills, organisational acumen, some personal charisma, leadership, presentational skills to ensure understanding at all levels, and a vision. He then went on to ask: what would I say to a potential replacement? His reply: there is no better way to develop yourself, to learn your own capabilities, and humbly to find out more about your own personality.
	That is why we can take pride and pleasure in volunteering. Pride, in that as other noble Lords have told us, according to the 2003 Home Office Citizenship Survey, 42 per cent of the population of England and Wales volunteered at least once during the previous 12 months, and pleasure in the social capital and good will that is generated by the commitment and generosity of this huge number of people.
	What can the Government do to help and encourage this activity? I agree with my noble friend Lady Pitkeathley that the Government are taking it very seriously. The noble Lord, Lord Best, also made the point. My right honourable friend the Chancellor of the Exchequer is also taking this seriously. He has recently started to chair a ministerial committee on this subject. His ambition is to get 1 million more young people into volunteering by the end of the decade. One way I think that he can do this is to enable young people to gain qualifications while they volunteer. At present, it is hard to engage with an NVQ or other qualification and be a volunteer at the same time. I think that the Government can play an important role in facilitating this, and I hope that my noble friend the Minister will explore this with colleagues from the Department for Education and Skills.
	As I indicated earlier, there are signs in some sectors that volunteers are deterred by the legal, personal and financial responsibilities that they carry, not only while they are active but during the six years after they have moved on. Something could be done to make this less onerous, and I hope that my noble friend the Minister will look at this with colleagues from the Lord Chancellor's Department. It is also important for the Government to encourage—not force—each community to review its own voluntary sector. We are a diverse society, and as in all areas of social activity, the voluntary sector cannot develop on the basis of one size fits all. All communities develop in their own unique way. As my noble friend Lord Brooke of Alverthorpe said, the more that communities generate social capital, the greater the hope for sustained social cohesion. Over the years, this has happened in a haphazard way—needs and interests come and go. Mapping the voluntary activity in a community is therefore important evidence for a community to develop its own strategy and planning. This is of fundamental importance to volunteering in any community.
	I say this with confidence because I have been closely involved in just such an exercise. I declare an interest as president of Jewish Policy Research, which is in many ways the Jewish community's social think tank. Over six years, from 1997 to 2003, 13 studies were published providing vital data and analysis of the Jewish voluntary sector. In the words of the study, it was
	"looking at the glue that binds the community together".
	This study has been enormously helpful in ensuring that the work of the voluntary organisations is more tangible, effective and meaningful. This project was also partly motivated by the need to think through the implications of the Government's policy to rely increasingly on the voluntary sector to provide services and facilitate citizenship participation—a point made by my noble friend Lady Morgan. To achieve this, a great deal rests on the success of the minority voluntary sectors, and the evidence from research by Jewish Policy Research is enormously encouraging. This work was carried out with the encouragement of the Home Office, and I hope that the Minister will use it as a model of good practice to help other groups.
	I agree with the noble Baroness, Lady Emerton, that volunteering is not just a matter of raising money. With 42 per cent of the population participating, it is far more important than that. Its importance lies in it being the opposite of anti-social behaviour. Ministers have rightly been tough on anti-social behaviour, but have they done enough to encourage volunteering, which, as my noble friend Lady Pitkeathley put it, is pro-social behaviour? I have tried to indicate what they can do, and what voluntary organisations can do to help themselves.

Lord Ramsbotham: My Lords, I join all those who have thanked the noble Lord, Lord Goodlad, for giving us this opportunity to raise issues connected with an important part of our national life.
	I begin with two apologies. First, as a former Inspector General of the Territorial Army, I am not going to speak about the enormous contribution that the voluntary forces make and continue to make to our operations overseas. I know that all members of this House have paid tribute to that contribution and will pay tribute whenever it is mentioned. In recompense, I am wearing the cufflinks that were given to me when I retired. My second apology is to the Minister, because, unfortunately, the point that I want to make is really for a ministry other than the one for which she is responsible. I hope that she may bear the tidings to where I wish to send them.
	I must declare an interest, in that I am an office holder of a number of voluntary organisations, many of them connected with the penal world. In those various posts, I recognise the cautions that the noble Lord, Lord Goodlad, raised in relation to the activities connected with VAT. I also recognise the cautions that have been raised by a number of people about the involvement of bureaucracy and the increasing amount of paperwork.
	I will interject an interesting statistic, which was given to me by the chairman of a voluntary organisation; it is the sort of information that the noble Lord, Lord Brooke of Sutton Mandeville, is so good at supplying this House. There are 54 words in the Lord's Prayer—71 if you include the addition and the Amen. There are 277 words in the 10 Commandments. There are 300 words in the American Declaration of Independence. There are 26,911 words in the European directive on the export of duck eggs. This has little to do with the voluntary sector, except that it illustrates the exponential increase in paperwork.
	I want to concentrate on something to which the noble Baroness, Lady Pitkeathley, and the noble Lord, Lord Haskel, have referred—the involvement of the voluntary sector in what might be called pro-social behaviour and, in particular, the contribution that the voluntary sector and volunteers can make to both the penal system as a whole and the conduct of looking after offenders in prison and in the community.
	The aim of the criminal justice system is to protect the public by preventing crime and, better, re-crime—in other words, reoffending. Last September, the present Home Secretary enunciated a marvellous vision of how he would like to see that operated. He sees this as being delivered by a partnership involving the public, the private and the not-for-profit sectors, all concentrating on the needs of individuals and contributing as best they can to providing what is needed to help those people to live useful and law-abiding lives, both in custody and in the community. I agree with him entirely. Having seen many examples and being involved with some of them, I believe that this partnership should be a partnership in the best sense of the word, in that each of the three areas—the public, the private and the not-for-profit sectors—should provide what they can to aggregate the contribution of each.
	The role of the voluntary sector is vast. It covers penal organisations discussing policy, watchdogs that serve in individual establishments, visitors, help with all kinds of offending behaviour treatment, drug treatment, looking after families, providing work and education and so on—all of which is encapsulated in the splendid document What can I do?, published by another voluntary organisation, the Bourne Trust, which previously concentrated on Catholic prisoners. I am absolutely fascinated by the width and breadth of what the sector does, the numbers involved and the fact that its help is given in so many areas of the country so freely without people seeking any reward other than the fact that they feel that they are doing something to help their community by protecting it in the longer term.
	However, in relation to arranging this partnership, I am very disturbed at a word that has crept into the vocabulary recently. This is the caution that I invite the Minister to note. I refer to the introduction of the word "contestability", which I understand is a Treasury word. Some people suggest that it refers to market testing. When applied in the penal sector, it is now suggested that that contestability includes the voluntary sector competing with both the private and the public sectors for contributing services. I suggest that that is an entirely false interpretation of the role and ethos of the voluntary sector. It does not compete for delivering services; it delivers services.
	As an office holder of an organisation, I am more than happy to invite the public to contribute money to help to deliver the service that will protect them, but I cannot in all honesty ask them for money to enable me to enter a competition with a private or a public sector for delivering that service. In the past four weeks, I have had two disturbing letters. One was from the Department for Education and Skills to me in my position as chairman of the Koestler Trust suggesting that the outcomes of my trust are not sufficiently in tune with the outcomes in the Government's Green Paper on reoffending, dated 15 December, and that potential funding from the Government is questionable. The arts do not deliver hard outcomes in terms of reoffending; they provide the means by which people can become engaged in the education and training that might provide the hard outcomes. Therefore, I suggest that that is the wrong word.
	Almost as disturbingly, two weeks ago, as president of UNLOCK, the National Association of Ex Prisoners, I received a letter from a regional offender manager inviting me to contribute £5,000 a year to the cost of a member of her staff who would be responsible for commissioning our services. I do not believe that as a voluntary organisation we should be asked to contribute to the staff of an official organisation.
	My caution, which I hope will be passed on, is that I do not believe that we can afford to lose the vital and unique contribution that the voluntary sector and volunteering can and do make to this pro-social behaviour. I ask the Government to bear that in mind in future.

Baroness Andrews: My Lords, it has been an excellent debate. I join all noble Lords who have congratulated the noble Lord, Lord Goodlad, on creating an opportunity for a debate that has been informed not only by expertise, as usual, but by a huge range of personal experience. I started listing the number of voluntary organisations in which noble Lords mentioned that they had been involved. When I reached 23, I gave up. I know that noble Lords actively support many more.
	I was intrigued by the reference by the noble Lord, Lord Brooke of Sutton Mandeville, to the oldest youth club in the world. It was my impression that your Lordships' House was the oldest youth club in the world, but volunteering is a cross-generational issue.
	The debate has been extremely wide-ranging. I hope that the noble Lord has taken great pleasure from that. It has also raised some complex issues and tensions in the relationships between the voluntary and the statutory sector. It has led us to think about the quality and the scope of our service; the way in which we express our obligations to the community; the way in which we relate as individuals to society; and the challenges and the prospects ahead. I welcome noble Lords' recognition of the central role that we in government give to the voluntary sector. It has never been greater; we are proud to do that.
	I will certainly not be able to answer all the questions that were raised, but I will do my best to deal with as many as I can. It is a joy as well as a challenge for me to wind up this debate, because my most anarchic years were spent in the voluntary sector, growing a charity that, I am delighted to say, eventually had an influence on policy on the way we look at how and where children and adults learn and what we can offer outside the school day. That has been extremely important in my life.
	It is also interesting to reflect, as some noble Lords have done, on the whole notion of philanthropy in the history of our state. It has moved from an individual preoccupation parallel to the notion of a Victorian-nightwatchman state through metamorphosis into the Welfare State, without losing the trust that is at the bedrock of that relationship, to now, where it takes different expression in different forms. It is a source of fascination to other countries, rightly so, because it is so different from the way in which they organise their services and public relationships.
	The noble Lord, Lord Goodlad, spoke eloquently about the scope and scale of the present configuration, and one of the most dramatic statistics for me is that last year the Charity Commission registered over 5,000 new charities. It is a phenomenally fast-growing sector, and there has been phenomenal new activity: an army of 600,000 volunteers. A staggering 20.4 million adults volunteered at least once a month in England in 2005. Yet, the noble Lord was right: we must look not just at quantity but at the quality and consistency of volunteering. That is one of the many challenges, as is keeping people's enthusiasm, giving them continuing opportunities and making sure that they know that they are valued. We have seen this afternoon huge diversity in the description of volunteering, from advocacy and the representation of the individual to action in all forms throughout the public services. It is the smaller charities that often have the most to give and are most vulnerable, and it is those charities that I have in mind when I talk about growing capacity and what we need to be able to do.
	As well as advocacy, speaking truth to power, attacking vested interests and reaching below the radar to the parts of the community that are silent and often invisible, we have taken the debate beyond the domestic agenda. Thanks to the noble Earl, Lord Sandwich, we had the opportunity of an international tour d'horizon. We looked at the changing role of volunteers abroad, who bring added value in greater skills and greater experience to build capacities in those countries and at how we could use the diaspora to go back and grow more voluntary activity. If we are serious about ending poverty and improving health and social care in those countries, that is exactly the way we need to go. That is a definite improvement, without losing the altruism and enthusiasm of young people, many of whom belong to us in this House.
	On the domestic agenda, I want to say three things. First, I want to set out why the Government believe so passionately that the VCS has a role not just in public services—although, my goodness, we are glad of its contribution—but in what they represent in innovation, free thinking, making us aware of the gaps in everything that we do as a society and so on. Secondly, I want to examine the notion of partnership, the relationship between VCS and government, and thirdly, to explore why we believe that local government reform and community empowerment are vital in tackling the power gap. I want to stress in all that, even if I do not use the terms, that at the core is a genuine commitment to independence. As the noble Baroness, Lady Hanham, said, without independence the sector does not exist. That is its greatest resource and our most precious asset.
	We are now working in a different context in the voluntary sector, not only because society is changing so fast but because there is more wealth, prosperity and opportunity. That makes us aware of the greater impact of disadvantage, of the concentrations of poverty and how we reach particular groups. We live in an increasingly ageing society, and it is delightful to hear from the noble Baroness, Lady Greengross, of the huge contribution that the older volunteer continues to make and makes in such a pro-social way. One of the great pleasures of the debate has been the emphasis on pro-social behaviour rather than anti-social activity. We are living in an age when traditional support mechanisms—the family, the Church—are breaking down; when there is greater mobility but weaker geographical ties; where there are limited resources, including environmental resources; and when there is a sense among some individuals and groups of a genuine powerlessness. All that increases the need for a voluntary sector that is strong and vibrant and a critical friend to government because of its diversity; its strength; the speed at which it can move; its ability to get communities that are very stressed to trust a group to act with it and on its behalf; and, above all, its innovation. Our task is to ask more but also to give more. We are therefore responsible for removing barriers.
	We see a step change in the extent to which public services are delivered by the VCS. That is not exploitation or transferring responsibility but, as my noble friend Lady Morgan said, transforming the sector. However, barriers remain. There are difficulties with access to investment and finance and a lack of infrastructure and capacity. It is sometimes very difficult to form partnerships. There is a perception that there is a threat to independence and an outdated legal and regulatory framework.
	The noble Lord, Lord Goodlad, asked me about the PAC report. We welcome the report's recommendations. One of our responses is to publish this spring a cross-Whitehall action plan that will address the barriers. It will bring together in one place all the opportunities available to the sector and announce flagship areas to be open to contestability, which is an important method for opening opportunity and driving up quality in services. It will set out frameworks and timetables for departments and local authorities to commit to agreed pathways. It will include challenging targets for increasing public service delivery, a question raised by my noble friend.
	Noble Lords talked about better partnership, more effective investment in capacity building and more proportionate regulation. They are all equally important. In the new landscape of partnership, there is a tension in contractual relationships that we must address. That is why the Compact that we introduced in 1998 is now entering a new generation of Compact Plus, which will not only distil principles but introduce a chap with some teeth, an independent Compact commissioner, who will be tasked with promoting the Compact and how it works in the context of public service and social care.
	We heard the beginnings of an interesting debate on social and health care from the noble Baroness, Lady Emerton, and the noble Lord, Lord Sutherland. That is a big challenge. The White Paper on health raises some important challenges for us, and the contractual arrangements, as set out by the noble Baroness, are very important. The noble Lord, Lord Sutherland, raised some extremely important point about carers that I should like to think about and which I shall certainly post on to the relevant Minister. The answer to his question about Alzheimer's is yes; the consultation has finished, but I am sure that his point will have been well taken.
	Moving on from Compact, the greater challenge is sustainability. Therefore, the ChangeUp Fund, which arose from the 2000 review to which my noble friend Lady Pitkeathley referred, is vital. Her speech was magnificent in bringing together coherently so much of what we are doing. The important thing about ChangeUp is that it will generate capacity support, which is what the sector needs, whether for technology, training or finance, supported by £80 million of additional investment originally and a further £70 million last year. The sector is in the driving seat. That is why we have set up Capacity Builders, which will take over the running of that fund.
	My noble friend also referred to Future Builders. It is a genuine innovation involving not just grants but loans. Yes, that creates certain fears in some quarters, but if we can increase capacity, how much stronger will be those front-line organisations? Again, the trick will be whether we can ensure that small charities benefit from such innovations.
	The noble Lord, Lord Best, referred to unclaimed assets. He was absolutely right to do so, because that brings us to one of the most interesting developments. He raised his fears that that might precipitate a take-over by government. I assure him that there is greater scope for the scheme to develop. It is not about the Government seizing assets to cover statutory obligations. Let me make that clear. Those youth-based voluntary and community organisations are best placed to make a real difference at grass-roots level. It is essential that the voluntary sector is informed at the very beginning of that process and continues its partnership explicitly. He will know that the Pre-Budget Report set out our position on that in some detail. I believe that a broad debate on that issue is important, and I look forward to seeing that take shape.
	The independence of the sector, as I keep emphasising, is extremely important. We have created a new environment for charitable giving, which is quite generous, but the noble Lord is right that, although we launched A Generous Society, there is still a resistance to giving—one sees it in the corporate sector—which we need to overcome. Part of our task in A Generous Society is a package of measures that builds on the legacy of the Giving Campaign and develops priorities such as expanding and making the most of the payroll-giving schemes; extending the notion of democracy and giving; and working with young people—the things that will instil a culture and a habit of giving from a very early age.
	The noble Lord, Lord Goodlad, asked about VAT. Before I answer him, I must say that one of the challenges is that, if we can work with the sector to promote regular and effective giving, we could get another £600 million to charities in the form of tax relief if the number of donations that were made used tax-efficient measures. It is extremely sad that we are not doing that. I am afraid that he will not be surprised by my reply. Tax reliefs and exemptions for charities and charitable giving in the UK are generous; they are worth over £2.5 billion a year. Existing reliefs from VAT on purchases made by charities are worth £200 million a year. No government have considered the issue of irrecoverable VAT more seriously than this Government. We have conducted two major reviews to see if we could find a solution. We have not been able to identify a solution that is practical and efficient, affordable and well targeted, but the debate will continue.
	The other thing that we need to do is to reduce regulation. Noble Lords have talked about bureaucracy. Having been at the end of the voluntary sector that is applying for grants, I know what the forms and the bureaucracy are like, and I wish that we could streamline much of that. We are introducing new concepts and better regulation in the Charities Bill, and we will take that further in the context of the cross-government better regulation agenda. We will respond shortly to the recommendations made by the Better Regulation Task Force in its report, Better Regulation for Civil Society. We welcome that report, and we very much want to help to develop the self-regulation of the sector.
	Several noble Lords, not least the noble Lord, Lord Addington and my noble friend Lord Haskel, referred to another barrier—risk and redress. Of course there is a fear of possible litigation. I think that it is a disproportionate fear, but we must address it in partnership to encourage sensible and proportionate risk management. I shall write to the noble Lord about the case he mentioned that involved sports training and volunteers, because I believe that I can give him some positive news about that. Last year, the Home Office paid for an additional 30,000 copies of an excellent book written by Volunteering England, which the noble Baroness will want to know about, entitled, Volunteers and the law. The same grant was used to enable the author to give regional seminars. It is helping, but clearly the Compensation Bill will have a role to play because of the provision about the clarification of the value of negligence.
	I am racing through my remarks because there is so much to say, but I shall now talk about volunteering. There has never been a better time to be a volunteer. We need to deal with some of the myths. Volunteering is not going out of fashion, and it is not the preserve of white, rather elderly ladies. Several noble Lords asked about the legacy of TimeBank UK, which has been remarkable. There have been record numbers of volunteers. Some 76 per cent were aged between 18 and 35, and more than 52 per cent came from a black or ethnic minority community. Some 2.2 billion minutes were pledged, as were 12 themed months, and 13,500 people registered on a dedicated website. There were also 3,000 national activities and events. Having been associated with this work, I was very pleased with campaigns such as TimeBank and Crime Concern encouraging more young black men to volunteer to mentor young people at risk of being involved in crime. Wonderful things have happened, and more will happen because the legacy will be built on. We have put more money into strategic grant aid to 14 voluntary charitable giving organisations, but, importantly, we must learn from all this, hence the importance of a full evaluation. We continue to set targets around volunteering. That is about opening more doors, which is what the year did. We will go on opening those doors. The Olympics will have a huge demand for volunteers.
	We have two specific programmes. The GoldStar programme is a two-year £5 million fund, which was launched in November. It is an exemplar programme that focuses on spreading good practice and how to recruit, manage and retain volunteers. However—very timely today—I can tell the House that we are attacking the barriers that stop many people, including those from BME communities, coming forward. Today, a Home Office Minister has confirmed that a new programme, Volunteering for All, will focus on raising awareness of volunteering and on removing some of the barriers to volunteering faced by the most excluded groups. The programme will help with the sort of issues that my noble friend Lord Haskel raised about qualifications. We know that the great asset for a volunteer is to discover his skills and to develop them, which will involve work with Jobcentre Plus developing relationships and skills at the same time. I would like to write to the noble Lord about that. There is a lot of interesting work on level 2 qualifications and the work that we are doing with DfES and the learning and skills councils to ensure that volunteers are enabled to benefit from that development.
	The recommendations of the Russell commission report, which we accepted in full, include accreditation, with which we will go forward. The Russell commission—which was informed by young people, not just informed by adults for young people—will be a most exciting development in terms of the new youth advisory board, which is made up of 20 young people, and the work that it will do.
	Several noble Lords raised complex issues about employment and the definition of volunteers. It would probably be safer if I wrote, but I was struck by the example of the RNLI. That is not alone, because there are other search and rescue services that fall into the same category. I know that that is a live debate in the Home Office. The RNLI was involved in a recent meeting. There are issues about a lack of consensus on the definition of a volunteer. Part of the problem is that we see the value of having a definition, but, at the same time, we do not want to run the risk of placing volunteering on a statutory footing. There are issues around the nature of contracts and employment that will have to be addressed. I understand that there is a cross-government search and rescue committee that exists to review the area. It will be informed, I think, by the commission mentioned by the noble Baroness, Lady Pitkeathley. I will write fully to explore that and to explain to the noble Lord how this sensible document fits into that.
	I am conscious that I have not been able to reply to the specific questions raised by the noble Lord, Lord Ramsbotham, and the noble Viscount, Lord Montgomery of Alamein. I will either pass their questions to a more competent Minister or I will write myself. I was interested in the work in Latin America that the noble Viscount mentioned.
	In winding up, I want to say briefly that we in ODPM have a particular care for the role of the volunteer, not least because of our work on renewal, regeneration and growing new communities. The noble Lord mentioned the words of David Miliband—double devolution—but, importantly, we will not be able to grow the sort of healthy, safe communities that we want to see without the role of the voluntary sector, which plays a very important role. Organisations such as Groundwork show that the environmental sector can engage and enthuse people's work-time and energy in astonishing ways, which is extremely important. As we move into new arrangements for local area agreements and so on, it is critical that in those new configurations the voluntary sector plays its role as centrally as possible.
	I am conscious of having spoken at great speed. I hope that I have addressed the most important issues raised. I congratulate the noble Lord, Lord Goodlad, again, on the opportunity that he has presented for an extremely welcome debate.

Lord Evans of Temple Guiting: My Lords, again I am grateful to the noble Baroness, Lady Hanham, and the noble Lord, Lord Thomas of Gresford, for their general welcome to the order. The noble Baroness, Lady Hanham, is not happy with the explanation that I gave for the delay. When I said that officials decided, I was not blaming the officials or avoiding ministerial responsibility. Officials felt it would cause great difficulties for the political parties and the candidates to bring in the report for the general election at such short notice. The noble Baroness has raised a point. I will talk again to officials and write to her if there is any further explanation for the 13-month delay.
	I am grateful to the noble Lord, Lord Thomas of Gresford, for pointing out spelling errors. They will be checked and corrected and I am sure the Electoral Commission will be extremely grateful for the compliment he has paid to its valuable work. We will discuss the issues with slightly more heat when the Government of Wales Bill appears in the House. I beg to move.

On Question, Motion agreed to.
	House adjourned at seven minutes past six o'clock.
	Thursday, 9 March 2006.